Tire Recycling Consultants

P.O. #:____________

Waste Tire and Wheel Processing
Equipment Sales & Leasing

     Fort Lauderdale, Florida 33329
     800-557-5692 Tel
     954-521-6040 V-Mail

Fax Back To: 888-761-4955

Purchase
Order

PURCHASER:

SHIP TO:

Name:
Address:
Phone:
Email:

Name:
Address:
Phone:
Email:

P.O. DATE	REQUISITIONER	SHIP VIA	F.O.B. POINT	TERMS
		GROUND		PRE-PAID

QTY.	DESCRIPTION	PRICE	TOTAL

PAYMENT TERMS:

	Visa		Check Enclosed: #
	MasterCard		Wire Transfer (Call for instructions)

SUBTOTAL
SALES TAX
SHIPPING

TOTAL

Credit Card #:	Exp. (MM/YY):
Billing Address:
City, State, Zip:
Signature:	____________________________________

NOTE: Fax this completed form to 888-761-4995.
If paying by check, fax this form, and mail completed form with check payment to the above address.