Wexco On-line Order form

Bill to Information	Ship to Information ship to same address
Order Date:	Date Requested By:
Your Name:	PO Number:
Job Title:	Attention:
Company:	Company:
Address 1:	Address 1:
Address 2:	Address 2:
City:	City:
State/Prov:	State/Prov:
Zipcode:	Zipcode:
Country:	Country:
Telephone:	Freight Carrier:
Fax:	Print Number:
Email:	Wexco Quote #:
Terms: To be determined	Quote Issue Date:
Expert Broker:
Special Shipping Instructions:
Wexco Drawing Number:
Qty Description Quoted price (include ID, OD, length, machine make and model, inlay)

Please include all necessary technical information, drawings, prints etc.
Attach documents with the order

All orders are subject to Wexco terms and conditions of sale. Acceptance and payment terms will be acknowledged upon receipt and confirmation of the order. Ship dates are subject to change pending receipt of all technical information to process the order.