Original copy

Page 1

ORIGINAL COPY

BROCK TOOL COMPANY

NUMBER

DATE

R-

1401 E. RIVERSIDE DR. INDIANAPOLIS, IN 46202 Ph. 317.634.7575 Fx. 317.636.0588

DATE SHIPPED

SERVING INDUSTRY AND CONTRACT ORS

ACCT. NO.:

SHIP VIA

CUSTOMER ORDER NUMBER

TAKEN BY

QUAN.

BROCK NO.

SHIPPED

MANUFACTURER

DESCRIPTION

MODEL NO.

SERIAL NO.

PER

FILLED BY

DISC.

PARTS LABOR

TYPE GIVE ESTIMATE

VOLTAGE NAME

NO CLAIMS OR RETURNS ALLOWED AFTER 6 DAYS OF RECEIPT OF SHIPMENT WITHOUT AUTHORIZATION

NEW TOOL WARRANTY

BROCK WARRANTY

TELEPHONE NUMBER SPECIAL INSTRUCTIONS

FREIGHT CHARGES

CREDIT

ESTIMATE APPROVED BY

DATE

P/C


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