| Primary Contact: | __________________________________ |
| Email: | __________________________________ |
| Phone: | __________________________________ |
| Fax: | __________________________________ |
| Accounts Payable Contact: | __________________________________ |
| Email: | __________________________________ |
| Phone: | __________________________________ |
| Fax: | __________________________________ |
| Purchase Order Number: | __________________________________ |
| Terms: | ___ Prepay Wire |
| | ___ Prepay Check |
| | ___ Other |
