Fax Order Form
| LPJ
CLEANING
SERVICES
Fax1(877)277-3504
FAX / MAIL ORDER FORM
8 LOCATIONS TO SERVE
YOU
Print form and fax
Westfield, MA Phoenix,
AZ Atlanta,
GA Columbus, OH Niles,
IL Elkridge, MD Grand
Prairie, TX |
Customer # ____________ Purchase Order_____________ Date_________
Phone Number __________ Fax Number ______________
Company Name____________________________ Address_______________
___________________________________
City ________________ State _________________ Zip ____________
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Net Terms ____ Check/Money Order Enclosed ____ Credit Card (see below)
Shipping and handling and state taxes will be applied !
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CREDIT CARD INFORMATION
Visa _ MasterCard _ Discover _ Amex _
CREDIT CARD NUMBER
Expiration Mo / Yr
____________________________
Card holder
signature
Mail to: P
O BOX 675253
Marietta, GA 30006
