Independent Ag Equipment

Attention: ________________________________ Order Date: __________________ Time Faxed: ________________________ Customer Number: ____________

Purchase Order No.: __________________________________________________ Bill to: ______________________________________________________________

Ship to: ____________________________________________________________ Company Name: ______________________________________________________ Attention:____________________________________________________________ Address: ____________________________________________________________ City, State, Zip: ______________________________________________________

Company Name: ______________________________________________________ Address: ____________________________________________________________ City, State, Zip: ______________________________________________________ Phone No.: __________________________________________________________ Fax No.: ____________________________________________________________ E-mail:______________________________________________________________

FAX ORDER FORM

COD UPS ground Mail

Ship via:

Next day air

2nd day air

Best way Truck

Visa, Mastercard, American Express Discover or Farm Plan No.: __________________________________________________________________ EXP. DATE: __________________

Ship complete orders

Ship from any available warehouse

Ok to back order

Warehouse Codes : PA -Biglerville, PA, OH -Bellevue, OH, IN -Bunker Hill, IN and B/O -Back order

AVAIL CATALOG YEAR UNIT EXTENDED

QUANTITY PART NO.

DESCRIPTION

WHSE AND PAGE NO.

PRICE PRICE

Special instructions: ____________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please call or fax back with a total of this order. Attention: ____________________________________________________ Please notify me if part numbers need to be back ordered

248 | INDEPENDENT AG EQUIPMENT PRODUCT CATALOG | PA: 800-345-3546 | OH: 800-848-8460 | IN: 888-563-1988 | www.IndependentAg.com