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Customer Information:
Name:*

Email:*

*Daytime Phone:

Fax:

Address to be shipped to:
If you would like the invoice sent to a separate address,
please note the address in the comments box below.
Ship to:*

City:*

State/Territory*:

Zip/Postal Code:*

Shipping Method:

Standard UPS Delivery
UPS second day air
Priority Mail
FedEx
Other,
Note: We will ship your order as soon as we can.

Backorders:
If we are out of stock on an item, how would you like us to handle it?
Please backorder any out-of-stock items.
Please cancel any backorders and adjust my total.
Please contact me regarding any out-of-stock items.

Please enter the quantity, description and price of each item below.
If you would like, we can enter the price.

`Qty`	`Item Description`	`Unit price`

If you need more room, just submit a second page
and note in the comments section below that the order is continued.

Method of payment:
MasterCard Visa
Check/Money Order
If Payment is by credit card:
My credit card information is listed to the right
I will call and leave my credit card number.
I will mail you my credit card number.

Credit Card Information:
Your name as it appears on credit card

Visa or MC number	Expires

Thanks for your business!

Any other comments or questions?
(Special shipping instructions? Product suggestions?)

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Central Pump Co. 1595 Mono Drive, Modesto, Ca 95354
Phone 209-524-9415 Fax 209-524-5945
sales@pumpsonline.com http://www.pumpsonline.com