Handley Industries, Ltd.
241 Lombard Street     Buffalo, New York 14212
(716) 893-5377     Fax (716) 895-5144

INTERNET ORDER FORM
please print this form, fill out by printing or typing, and then mail or fax to the above address

your customer account number                    your purchase order number                    today's date

Sold To
Business Name________________________

Your Name ___________________________

Address _____________________________

City, State, Zip ________________________

Daytime Phone  (       ) ___________________

Ship To: Only if different than Sold To address
Business Name________________________

Your Name ___________________________

Address _____________________________

City, State, Zip ________________________

Daytime Phone  (       ) ___________________

please circle one:    
payment enclosed        ship COD        charge to my VISA        charge to my MasterCard

Credit Card Number: __________________________________    Exp. Date: ____/____

Cardholder's Signature:  __________________________________________________

ship via:    
[] UPS Ground      [] 3 Day Ground      [] 2nd Day Air      [] Next Day Air      [] Other______

Quantity Stock No. Description Unit Price Total Price
         
         
         
         
         
         
         
         
Please Backorder            [] 
Substitute Similar Item   []   
Hold & Ship Complete   []  
No Backorders                []  

Authorized Signature:

  

Column Total  
Shipping  
Total Order $