Micro Parts & Supplies Order Form

Micro Parts & Supplies, Inc. PH (800) 336-2131 - (847) 516-0191

To place an order, complete the form and press the "SEND ORDER" button...

-- and the form is automatically sent to us^*

-- or you print the form and fax it to U.S.A.

847-516-0491

-- or you may send your purchase order to us:

MICRO PARTS & SUPPLIES, INC.
9606 Fox Shores Drive
Algonquin, Illinois 60102-9645
UNITED STATES OF AMERICA

-- or call our Ordering Department:

Toll Free 800-336-2131 (U.S.A. or Canada) or
+1.847.516.0191

We accept Visa, Master Card, American Express and Discover (Nova).
There is a minimum order of $30.00 in U.S. Dollars. In some cases other minimums may apply. Sales tax applies to Illinois residents.

CONFIDENTIALITY

Your information on this form is only for order processing and possible communication with you. No other company, individuals, agencies or others have access to this information.

Enter Order

Please provide the following product information:

Selection 1
Item #
Description
Price
Quantity
Selection 2
Item #
Description
Price
Quantity
Selection 3
Item #
Description
Price
Quantity
Selection 4
Item #
Description
Price
Quantity
Selection 5
Item #
Description
Price
Quantity
Selection 6
Item #
Description
Price
Quantity

Please provide the complete shipping address for you products.

	SHIPPING
Company
Attention
Name
ORDERED BY
PO#
Address1
Address2
City
State/Province Mandatory Entry
Zip/Postal Code Mandatory Entry
COUNTRY Mandatory Entry
TELE
E-MAIL
Please provide the complete billing address if different from the shipping address
	BILLING
Company
Attention
Name
ORDERED BY
PO#
Address1
Address2
City
State/Province
Zip/Postal Code
COUNTRY
TELE
E-MAIL

SHIPPER

Federal Express
United Parcel Service (UPS):

I'll arrange my own carrier:	(Check Box)

Use my FedEx Account Number

DROP SHIP -- Remember to include a packing slip and fill in your FEDEX shipping account number.

TERMS AND CONDITIONS OF PAYMENT:

Click here for Information for payment by electronic transfer (pdf format)

Payment by credit card (Please complete the billing address and telephone information if using a credit card.)

Credit Card
Cardholder Name
Card Number
EXPIRATION DATE (MO/YR)
Credit Card Verification Number	This number is a 3 or 4 digit number on the back of the card and to the right of the signature block.
Billing Address 1
Billing Address 2(Apt. #, Box)
City
State/ Province
Zip or Postal ID
Country*
Telephone
Name of Credit Card Bank*
Bank Address 1*
Bank Address 2*
Bank City*
Bank State/Province*
Bank Country*
Bank Telephone Number*

* If your credit card Bank is outside the USA and fails to support Address Verification and Credit Card Verification Number verification by electronic communication you must provide the Bank information shown in Red. Otherwise we will be unable to process your order.

If you know your 5 or 6 digit customer number, please enter here:

Click here if your company has Net Terms. Verification will be made before any order is confirmed, so be sure to enter your Customer# correctly.

CONTACT INFORMATION:

NAME Mandatory Entry
E-mail Mandatory Entry
TELE Mandatory Entry

COMMENTS AND SPECIAL INSTRUCTIONS:

Please contact me as soon as possible regarding this order.

READY TO PLACE ORDER NO ORDERS WILL BE PROCESSED UNLESS THE RESPONSE IS YES!

IF YES, PRESS

* Sending information by email or similar transmission does not guarantee the protection of your private information. However, your information is promptly removed from our password protected receiving site and is guarded in the same manner as all of the information you might submit by other means . In our 18 years of business we are unaware of any compromise of our customer information.

**************************************************************

Thank you for ordering from Micro Parts & Supplies, Inc. We appreciate your business.

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customerservice@mpsupplies.com

800 336 2131 (USA) or +1.847.516.0191