Order Form

( Print this page, fill-out by hand, and send by fax or mail )

Adaptas Scientific Instrument Services

9 Second Street Palmer, MA 01069 (413) 284-9975 Fax: (413) 284-9979 https://www.sisweb.com

Order Form Date:_____________

SOLD TO:

SHIP TO:

Method of Payment (select one)

• SIS Account
  Account Number_________________________
• Credit Card (select one) __ American Express __ Visa __ MasterCard
  Card Number:_______________
  Expiration Date:______________
  Credit Card Billing Name:_______________
• COD

Purchase Order #:_____________________________
Name:______________________________________
Phone:_____________________________________
E-Mail:____________________________________

Minimum order $40.00. Orders under $40.00 will be accessed a handling fee to $40.00.

Part #	Description	Unit Price	Quantity	totals
subtotal =
Tax =
Shipping charges =
Other charges =
Total =

Additional Comments:

ALL CLAIMS FOR ERRORS OR SHORTAGES MUST BE MADE WITHIN 10 DAYS AFTER RECEIPT OF GOODS. NO GOODS MAY BE RETURNED WITHOUT PERMISSION.

TERMS-NET 30 DAYS. A SERVICE CHARGE OF 1 1/2 PER MONTH (18% PER ANNUM) WILL BE CHARGED ON ALL PAST DUE ACCOUNTS.