Wexco On-line Order form

Maximize Machine Uptime

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Wexco On-line Order form

Bill to Information

Ship to Information

Order Date:

PO Number:

Your Name:

Attention:

Job Title:

Company:

Address 1:

Address 2:

City:

State/Prov:

Zipcode:

Country:

Freight Carrier:

Telephone:

Date Requested By:

Fax:

Print Number:

Email:

Wexco Quote #:

Terms: To be determined

Quote Issue Date:

Expert Broker

Special Shipping Instructions

Wexco Drawing Number

Qty	Description (include ID, OD , length, machine make and model, inlay)	Quoted price

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.

Wexco Corporation, 1015 Dillard Drive, Lynchburg, VA 24502

(800) 999-3926