PURCHASE ORDER Date: ___________

Print this form, complete the information and fax to:
712-881-2211
  Your PO No: ____________________   Vendor: Graham Systems, Inc.
  Company Name: _____________________     206 N 8th St
  Ordered By: _________________________     Mapleton, IA 51034
  Phone: ______________   Fax: _____________     Phone: (515) 577-6792
  Email: __________________________     Fax: (712) 881-2211
    Ship To:    
  Attn: ______________________      
  Address: _____________________________      
    _____________________________      
  City, State Zip ______________________, _____ ________      
           
    Bill To: Same as Shipping      
  Attn: ______________________      
  Address: _____________________________      
    _____________________________      
  City, State Zip _______________________, _____ ________
 
     
Line Qty... Part Number Description............................................. Unit Price ....Ext. Price
1 . . . . .
2 . . . . .
3 . . . . .
4 . . . . .
5 . . . . .
        SubTotal $
 
Payment Details
Check            Account No. _________  
Credit Card,  Name on Card: _______________  Card No. __________________ 
    Exp. Date:  Mo.____ Yr. ____  
6% Sale Tax for Orders Shipped to Iowa Handling Charge $5.00 for packages 1-34 lbs,
$7.00 for packages 35-70 lbs.
Shipping Method: ________________________

Acknowledge Order By: ___________ to: __________________

  Special Instructions: __________________________________________________________
__________________________________________________________
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