Fax Order Form
Order Date: ________________________
Print this form on your local printer. You may also: Save this form as a simple TEXT file, fill
out the form on your computer and email the text file to
orders@digi-trax.com
For Overnight Orders: Please
call 847-613-2100, option 2, to confirm receipt of order.
Customer Name: _______________________ Customer/ Account
# (optional): ______________
P.O #: ________________________________________________________________________
Ship To Address: _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Attention To: __________________________________________________________
Item # / Description_____________________________Quantity__Price__________
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
4.____________________________________________________________________________
5.____________________________________________________________________________
6.____________________________________________________________________________
7.____________________________________________________________________________
8.____________________________________________________________________________
Ship Via: ___________________________ Contact Name (required): _____________________
Phone Number (required): ________________________ Fax: ___________________________
E-mail address: _________________________________________________________________
Credit Card Purchase:
Visa______ Mastercard______ American
Express______
Credit Card Number: __________________________________
Expiration:_________________
Verification Number on back, usually 3 digit #:_____________
Card Holder Name/ Company: _____________________________________________________
Credit Card Billing Address: _______________________________________________________
______________________________________________________________________________
City, State, Zip: ________________________________________________________________
Special Instructions:_____________________________________________________________