PURCHASE ORDER FORM (Please take the Print out of this form on printer for use)
NO. ITEM DESCRIPTION QUANTITY UNIT PRICE TOTAL AMOUNT 1 2 3 4 5 6 7 8 9 10 Sales Tax @ 8.75% for ILLINOIS State USA Customers Only
Shipping Charges
GRAND TOTAL US$
PAYMENT OPTION ( Money Order Or Certified Cheque must be in US $ and Payable in USA)
If Credit Card Payment, please provide the following Information (Use CAPITAL LETTERS)
Credit Card Type: _____________________ ( Visa, Master Card OR Discover )
Credit Card Number: __________________________________ ( 16 Digit Account Number )
Credit Card Expiration Date: ____________________________ ( MM/YY )
Card Holder's Name On Credit Card: __________________________________
Card Issuer Bank and Phone Number: ___________________________________________
First Name: ______________________________ Last Name: ______________________________
Billing / Shipping Address: ( In case of Credit card, Address Where Credit Card Statements are received )
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
State / Province: _______________________ Country: ______________________Postal Code: _________
Phone (Optional) : ________________________E-Mail (Optional): __________________________________
Additional Information: _____________________________________________________________________
I read, understand and agree with the Order and return policy http://www.alldual.com/policy/policy.htm , By providing above Information I am providing authority to Audio Video Electronics and Appliances to charge on my credit card or Money Order or Certified Cheque for this purchase order
Signature ____________________________________________ Date: ______________________________
Mail Purchase order to: Audio Video electronics, 2424 West Dewon Ave., Chicago IL 60659 USA
Toll Free Tel: 1-877-207-8570; Fax: 1-773-973-6869 E-Mail: info@alldual.com