5614 S.W. 25 Street, Hollywood, FL  33023,  Ph:  (954) 966-7329,  Fax: (954) 966-3584

Fax Order Form
Directions: (1) Type info into blank fields, (2) Print it out,
(3) Fax completed order form to (954) 966-3584.

BILL TO:

Name:
Company / PO# (if any):

Address:

City, State  Zip Code:

Country:

Phone:

Fax:

Email:

SHIP TO
(if different from billing address):

Name / Tail# or Boat Name (if any):

Company:

Address:

City, State  Zip Code:

Country:

Phone:

Fax:



Credit Card #: VS   MC Disc Amex

Expiration Date / Security Code (3# on back of card):
Quanity Part Number Description
Buy Rent Service
Price
Total:
PURCHASE: Specify if needed by certain trip date:
RENTAL:  Date Needed by:  Approx. Return Date:
SERVICE: Regular Turnaround (2-3 weeks)   
                     Expedite (2-3 days/25% additional of total cost)   Date Needed by:
Delivery:  UPS Ground    Next Day    2nd Day    3rd Day    Customer Pickup 
Special Shipping Instructions (if any):
 
Signature:________________________________________ Date:
   
Note:  For shipping back rentals or service work, contact our Shipping Rep., Jeff Heidenreich at Freightquote.com.
Ph:  (785) 783-4560, Email:  jheidenreich@freightquote.com for most economical shipping quote cost.
 
PLEASE CALL (954) 966-7329 OR EMAIL sales@survivalproductsinc.com TO CONFIRM ORDER WAS RECEIVED.