Purchase ORDER FORM

PLEASE PRINT CLEARLY


NAME________________________________________________

ADDRESS_____________________________________________

CITY__________________STATE_____ZIP_________________

PHONE NO.____(_____)__________-______________________

OHIO VENDOR'S # IF AVAILABLE_______________________
AEGEAN SPONGE CO.
 4722 Memphis Avenue
Cleveland, OH 44144-1915
tel: (216) 749-1927
fax: (216) 749-2110
CALL TOLL FREE ..1 - 800 - 276 - 8542
e-mail: jplimnos@att.net
MasterCard TM


QUANTITY
 CAT.
NUMBER
DESCRIPTION
 UNIT
PRICE
AMOUNT
 PLEASE DO NOT
WRITE BELOW
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           

Date of Order_________COD______VISA_____MASTERCARD______
Ohio residents only (Vendors # or add 8% sales tax)

METHOD OF PAYMENT

____Check or Money Order Enclosed
(Payable to Aegean Sponge co.)

Credit Card
Number:__________________________________

Expiration Date: Month______ Year________

Cardholder Name:________________________________________

Signature:_______________________________________________

TOTAL
    
17% ESTIMATED
SHIPPING
    
OHIO
SALES TAX
    
TOTAL
BALANCE DUE
    
AMOUNT
ENCLOSED
    

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