Southland Industrial Supply, Inc.

Order Form

Bill To: _________________________ Ship To: ___________________________

_________________________ ___________________________

_________________________ ___________________________

Phone : _________________________ Phone: ___________________________

Fax: _________________________ Fax: ___________________________

Contact: _________________________ Contact: ___________________________

Purchase Order #________________________

Credit Card # ________________________________________ Expiration _______________

$50.00 minimum on Credit Card orders. Visa ______ Master Card ______

Quantity Product Code Description Unit Price Extension

Approved By: ____________________________________

Buyer: ____________________________________

UPS Ground shipments freight prepaid on orders $250.00 or more.

FAX TO 770-531-0781 CALL 1-800-334-6743 OR 770-534-3898