ORDER FORM - Sargent Welch
ORDER FORM - Sargent Welch ORDER FORM - Sargent Welch
Post Office Box 4130• Buffalo, New York 14217 phone: 800 727-4368 • fax: 800 676-2540 sargentwelchcs@vwr.com • sargentwelch.com Sargent–Welch Account Number: ____________________ ORDER FORM Shipping Information School: _______________________________________________ Teacher Name: _____________________ Title: __________ Address: _____________________________________________ Purchase Order #: ____________________________________ Date: _________________________________________________ Billing Information (If different than Shipping Info.) School or District: ____________________________________ Address: _____________________________________________ City: ____________________________ State: ______________ City: _____________________________ State: _____________ Zip: _______________Telephone: ( )__________________ Zip: _________________Telephone: ( ) _______________ signature Approved By: ________________________________________ Email: ______________________________________________ Email: ________________________________________________ ___ Page Unit Qty. Catalog Number Description No. Price Total * All Live Orders Must Indicate Ship to Arrive Date Check/Credit Card Orders o Visa o MasterCard o American Express o Discover Card #: Expiration Date:___________________________________________________________ Cardholder’s Signature: ___________________________________________________ o Check Enclosed Check Number:__________________________________ Subtotal from Other Side: Merchandise Total: Shipping Charge: Subtotal: Tax: (if applicable) Total:
Post Office Box 4130• Buffalo, New York 14217<br />
phone: 800 727-4368 • fax: 800 676-2540<br />
sargentwelchcs@vwr.com • sargentwelch.com<br />
<strong>Sargent</strong>–<strong>Welch</strong> Account Number: ____________________<br />
<strong>ORDER</strong> <strong>FORM</strong><br />
Shipping Information<br />
School: _______________________________________________<br />
Teacher Name: _____________________ Title: __________<br />
Address: _____________________________________________<br />
Purchase Order #: ____________________________________<br />
Date: _________________________________________________<br />
Billing Information (If different than Shipping Info.)<br />
School or District: ____________________________________<br />
Address: _____________________________________________<br />
City: ____________________________ State: ______________<br />
City: _____________________________ State: _____________<br />
Zip: _______________Telephone: (<br />
)__________________<br />
Zip: _________________Telephone: (<br />
) _______________<br />
signature<br />
Approved By: ________________________________________<br />
Email: ______________________________________________ Email: ________________________________________________<br />
___<br />
Page Unit<br />
Qty. Catalog Number Description No. Price Total<br />
* All Live Orders Must Indicate Ship to Arrive Date<br />
Check/Credit Card Orders<br />
o Visa o MasterCard o American Express o Discover<br />
Card #:<br />
Expiration Date:___________________________________________________________<br />
Cardholder’s Signature: ___________________________________________________<br />
o Check Enclosed Check Number:__________________________________<br />
Subtotal from Other<br />
Side:<br />
Merchandise Total:<br />
Shipping Charge:<br />
Subtotal:<br />
Tax: (if applicable)<br />
Total:
Post Office Box 4130<br />
Buffalo, New York 14217<br />
phone: 800 727-4368<br />
fax: 800 676-2540<br />
customerservice@sargentwelch.com<br />
sargentwelch.com<br />
Customers Outside the U.S.<br />
phone: 585 359-2502<br />
fax: 585 334-6174<br />
Page Unit<br />
Qty. Catalog Number Description No. Price Total<br />
* All Live Orders Must Indicate Ship to Arrive Date<br />
Subtotal
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