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_______________ 

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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 !

  Item Number                          QTY                    Description  Price          EXT
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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