SIMCO Order Form

Step One: Contact Information
Items in red are required

Name:

Title / Position:

Please select all that apply: At least one is required

	Send Catalog	Request Sample
	Place Order	Have Salesman Call

Company Name:

Email Address:

Phone Number / Extension:

Fax:

Next

Step Two: Product Description

Use this for product description, even though you are requesting a Sample.

Quantity	Model Number	Product Description





Comments		Back Next

Step Three: Billing & Shipping

Billing Address

Address

City & State

Zip Code

Shipping Address

Address

City & State

Zip Code

Back Next

Step Four: Billing & Shipping

Shipping Company

United Parcel Service (UPS)

Postal Service
Federal Express (Fed Ex) Fed Ex #


If you are shipping Fed Ex, you must supply a Fed Ex number or the order will not ship.

Please allow 24 hrs for shipping

If you are requesting a Sample please skip Payment Terms and click the summit button when you are finished.

Payment Terms

COD
NET 30

Purchase Order #