Order Form

Great Products, Great Prices, Direct To You
Phone:(630)230-0600 Fax:(630)230-0606
www.electricsupplydirect.com

To manually order products. Print this page, complete the form below and fax order to (630) 230-0606

Item	Description	Quantity	Price	Total










Shipping*
Total

* Shipping charges are $5.00 for all order less than $30.00. All other orders are free of shipping charges.

Contact Information
First Name :
Last Name :
Shipping Address :

City :
State / Province :
Zip / Postal Code :
Country :
Billing Information
Billing Address
(only if different from shipping address):
Cardholder's Name :
Credit Card Number (no spacing):
Expiration (MMYY) :
Signature