Durapak Supplies  
Print this form and MAIL or FAX to:
1900 Tyler Ave./ Suite N / S. El Monte, CA / 91733
Fax: (626) 737-1726 Ph: (877) 387-2725
www.durapak.net
  
     
 
* You must fill in all fields
E-mail _____________________________
Full Name _____________________________
St Address _____________________________
City _____________________________
State Zip Code _____________________________
Country _____________________________
Day Phone _____________________________
 
     Check here if same as billing information
Full Name _____________________________
St Address _____________________________
City _____________________________
State Zip Code _____________________________
Country _____________________________
Day Phone _____________________________
Other Phone _____________________________
 
       
 
Amex, Discover ok                                        

Credit Card Details
Credit Card # ____________________________________

Exp (mm/yy) ____________________________________

Exact Name on Credit Card ________________________

CVV Code on back of card: ________________________

Customer Signature ______________________________
 
   
 
       Quantity Item Name Item# Price Total
1          
2          
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4          
5          
6          
Product Sub Total  
Shipping  
California Addresses add 10.25% Sales Tax or submit California Resale Certificate  
Total  
 
 
Print This Form        (sales tax on product only, not shipping)