Purchase Requisition for Imprinted Service Order

IDN:
IDN Ref/PO:
Date:
Ship To:
Street Address: (not P.O Box, for UPS Delivery)
City:
State:
Zip:
Dealer Order #:
Phone No. of Contact Person:
Contact Person:
Email:

Please check box for exact repeat from previous order
Company Imprint:
Address:
City:
State:
Zip:
Phone No. for Imprint:
Other Imprint Information: (ex. Company Web Address)

Special Instructions for this Order:

Imprint cost includes 5 lines at top and 2 lines on claim check.
Instructions: Forms must be ordered in case lots of 1,000 (minimum order 1,000). Costs do not include shipping. Complete all infomation above and below. Allow 3-4 weeks for delivery. Forward to your Briggs & Stratton Central Sales & Service Distributor.
Please enter a value for each field in the form below. If a number is not required to fulfill your order, please enter a "0" in that field. This form will not be processed if fields are left blank.
	Size	Price Per 1,000	Quantity	Price Extension
273181 Repair Order Form without Laminate	8.5 x 11	$160.00
273189 Repair Order Form with Laminate	8.5 x 11	$180.00
273279 Repair Tag with Laminate	4.25 x 8.5	$110.00
Logo (Extra Charge)		$60.00
Logo On File: Yes No
Additional Charge for More that 5 Lines of Copy at Top and 2 Lines on Claim Check		$6.00/Line
State Sales Tax:
TOTAL: