Halibrite Airfield Lighting / Order Form

Hali-Brite Inc. Order Form

Print & mail or fax this form to:
Order Desk
Hali-Brite Inc.
PO Box 10
Crosby, MN 56441

Date _____________: Phone: 1-800-553-6269; Fax: 1-218-546-6854; Hours: 8:00am to 5:00pm M-F

Ship to: ______________________________________

______________________________________

Bill to: ________________________________________

________________________________________

Your Name: _________________________________
Company: _________________________________
PO#
_____________________________

Phone: ___________________________________
Fax: ___________________________________
Ship Via: ___________________________________

Qty	Part #	Description	Unit Price	Total Price

Please check proper lines:
___ Cancel backorders after ____ days
___ Pre-Paid Order (Please include check)
___ COD Order
___ Open Account (Pending approved credit)
___ Visa - Account # ___________________________________
___ MasterCard Account # ______________________________
___ Expiration Dates _________ to ___________

Cardholders Signature __________________________________

Sub-Total ___________

Shipping ____________

Total _______________

Signature _____________________________________________

Title__________________________________________________

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