ORDER FORM
325 Spring Lake Drive Itasca, IL 60143-2072
Fax or Mail This Form
STEP 2: SHIP TO(If different than bill to)
STEP 1: BILL TO Name (please print)
Name (please print)
Municipality / Agency / Company
Municipality / Agency / Company
Mailing Address
Mailing Address
City
State
Phone
Fax
City
Zip
State
Phone
Zip
Fax
(NOTE: We cannot ship to a P.O. Box; please supply street address)
STEP 3: TYPE OF PAYMENT Credit Card
Check / Money Order Enclosed
Open Account
VISA
Card Number
Security Code
MasterCard
American Express
Expiration Date
/
/
Signature
OPEN ACCOUNT
Customer Account Number
Purchase Order # See “Terms & Conditions” for New Account information
Check / Money Order sent with this order $
STEP 4: PRODUCTS Qty. Darley® Number
Color
Size
Item Description
Ship Wt.
Price Each
Total Price
1. 2. 3. 4. 5. 6. 7.
ORDER FORM S
8. 9. Order Subtotal
UPS Shipping and Handling Charges for Pre-Paid Orders Merchandise Charge 0-$25.00 ......................................$6.95 $25.01 - $50.00 ..........................$8.95 $50.01 - $100.00 ......................$10.95 $100.01 - $200.00 ....................$14.95
Merchandise
$200.01 $300.01 $400.01 $500.01
Charge
- $300.00....................$18.95 - $400.00....................$21.95 - $500.00....................$24.95 and up .............3% of Order
• Your order will ship the most economical way unless otherwise requested. • Prices only apply to UPS orders only, not items shipped motor freight.
Shipping Sales Tax (if applicable)
TOTAL AMOUNT For questions on sizing, please call our friendly sales staff at 1-800-323-0244
SALES TAX* IA = 6% plus local county tax; IL = 7.75% or 8.75% if delivery is made in Chicago; AZ = 6% + county taxes; CA = state rate is 6% + county and possibly district taxes; WI = 5% plus local county tax; GA = 4%; NC = 4.75%; PA = 5% plus an additional 1% for sales into Philadelphia and an additional 1% for sales into Allegheny county; TN = 7%, CO = 2.9% + possibly city, county & district taxes; VA = 5%, OH = 6.5%. State laws require us to have your signed exempt/resale certificate on file at our offices. We will be forced to charge you sales tax, if we do not have this documentation. All sales to individuals in these listed states are always taxable.
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1.800.323.0244 | www.edarley.com