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 Groupís 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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Method of Payment:

C.O.D†††††††††††††††††††††††††††††††††††††††††† ††††† Authorized Signature: _________________________________

VISA††††††††††††††††††††††††††††††††††††††††††††††††††††††† †††††† Card Number: _________________________________

MasterCard†††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Exp. Date: _________________________________

American Express†††††††††††††††††††††††† Cardholder Name: _________________________________