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Sample Request Form

SHIP TO			BILL TO
Company Name			Company Name
Street Address			Street Address
City, State Zip			City, State Zip
Contact Name			Contact Name
Telephone #			Telephone #
ITEM NO.	XMULTIPLE PART #	DESCRIPTION		QTY	UNIT COST		EXTEND COST	TOTAL AMOUNT
Ordered By: Authorized By: SPECIAL INSTRUCTIONS:						Subtotal
						Shipping Charges
						Handling Charges
						Insurance
						Tax
						Total Due

543 Country Club Drive #B-128 • Simi Valley, CA 93065 USA • (805) 578-9076 • FAX: (805) 498-4003

Fax Sample Request to 805-498-4003 or Email sales@xmultiple.com

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