7530 DiSalle Blvd. Ft. Wayne, IN 46825 260-489-7787 Fax: 260-489-8161		Date Requested Ship Date Customer Purchase Order No.
ORDER FORM

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SOLD TO SHIP TO (IF DIFFERENT THAN SOLD TO) Name Address City State Zip Code Phone Email Address: Name Address City State Zip Code Phone Email Address: Items To Be Ordered Quantity Part Number Description Comments: ORDERED BY:       Please fill out the above information, Print a copy, and then press the Submit button. This order is subject to the TERMS and conditions of Viking Business Products Inc. TERMS: NET 30 DAYS