ASTRA M GROUP LTD.

10-100 Westmore Drive, Toronto, ON M9V 5C3

Tel: 416-746-6458 Toll Free: 1-866-996-9908

Fax: 416-746-9612 E-mail: info@astramgroup.com web: www.astramgroup.com

PARTS ORDER FORM Date: _______________________________
BILL TO: Astra M Group Acct# __________________ P.O # _______________________________
Company Name: ___________________________________ Contact Name: ____________________________
Address: ____________________________________________________________________________
City: ______________________ State/Province: ____________ Zip/Postal Code: _______________ E-mail: ____________________________________________________________________________ Phone: ________________________________ Fax: ________________________________________ PST Exempt # (if applicable): __________________________________________________________________
SHIP TO:				SHIPPING:
Company Name: ____________________________________				Astra M Group’s Acct. & Invoice us: □
Address: _____________________________________				Ship on a customer account: □
City: _____________________________________ State/Province: ____________ Zip/Postal Code: ___________ Contact Name: _____________________________________ Phone: _____________________________________ Fax:_____________________________________				Shipping Company _______________ Account # ______________________
Line #	Quantity	Part #	Description		Unit Price	Total Price
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					Sub Total:
Method of Payment:
 C.O.D Authorized Signature: _________________________________
 VISA Card Number: _________________________________
 MasterCard Exp. Date: _________________________________
 American Express Cardholder Name: _________________________________