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SUPPLY / EQUIPMENT
If you have an account number you may simply fill in that field.

 
 

 Customer Information

 
Contact Name:

First:

Last:
Company Name:
Billing Address:
Account Number:
PO#:

To set up a new account go to on-line forms/ New Acct.

 use if you need a P.O, #
Payment Method:
Quote#:

cash / checks must be received before delivery unless otherwise approved. For credit fill out our on-line form.

 use if you called in for a quote
Credit Card Type: Name on Card:
Credit Card #:   include spaces
#'s on Back of Card:   in signature box
Expiration Date:
Phone # at:
Work:
Home:
*optional
 
Fax #:
Mobile:
*optional
E-Mail Address:
           

Equipment

Condition

Name & Model #

Qty.

Price
Upon ordering you will be contacted for confirmation with the total price .

Supplies & Products
Item type Item # or description Qty. Price
ex.  paper, toner, furniture or brand name  Upon ordering you will be contacted for confirmation with the total price .

Delivery Information
Delivery Information:
Delivery Address:
Delivery options if other specify in special instructions below
Preferred Contact Method
Special Instructions:

 

 

 Illinois Blueprint Corporation
800 S. W. Jefferson Avenue
Peoria, IL. 61605-3943
PH.  (309) 676-1300
FAX.  (309)-676-1310

Copyright Illinois Blueprint Corporation 2003