WILLMAR ROTARY TOOL-BASSETTMAIL/FAX Easy Order Form
Print and use this form when ordering by mail or fax(FAX: 1-616-676-1287)
Please Check One     Quote         Order

• Quote to / Ship to : Name: ________________________________________________
• Contact Name:_________________________________________________________
• Address: ______________________________________________________________
• City: _________________________________________ State: _____ Zip: __________
• Telephone: __________________________ Fax: ______________________________
• E-mail Address: _________________________________________________________
• Method of Payment: Money Order, Bank Draft, VISA, Master Card, Discover, AmExpress  ( circle one )
• Credit Card Number: ____________________________________ Exp. Date: _______
• Name on Card: _________________________________________________________
• Card Address:  _________________________________________________________
• City: __________________________________________ State: _____ Zip: _________
• Telephone: _________________________ Fax: _______________________________
• Authorized Signature: _______________________________________ Date:________