4apc.com
5299 Beach Road
Troy, Michigan 48098-2447

Items Ordered:

	Quan	Part #	Description	Unit cost
1.
2.
3.

Shipping Address:

To whom should this order be sent?

Name and/or department   
Street Address   
Street Address   
City or Town     State     ZIP   
Phone No.     Ext.   

Billing Address:

To whom should this order be billed? (Fill out only if different from shipping address.)

Name of payer, department
Street Address   
Street Address   
City or Town     State     ZIP   
Phone No.     Ext.   

Payment Method:

Select from one of the following:   Money Order Check Fedex COD UPS COD Purchase Order Other

Check no., PO no., or other detail:   

Special information:   

Shipping Method:

Select from one of the following:   Fedex AM Fedex PM Fedex Two-day UPS Next Day UPS Two-day UPS Ground USPS Priority

Contact Info:

In order that we may inform you when your order has been processed, please tell us your:

email Address:   

Daytime Phone:      Ext.: