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On-Line Order Form 
To order, please fill in the information below.
The ** indicates information that must be provided to properly process your order.
If you have any questions, please do not  hesitate to inquire through email
or call us direct at the above number.
Remember do NOT use the ENTER KEY on this page. (Tab Key or Mouse only)
Task Lighting Products
CLICK HERE for Ajusco Price Chart
#1: Contact Information
P.O. # Date:
Account #: Quote #:
Contact Name: Contact Phone:
BILL TO :
Company/Name: ** Address: **
City: ** State/Prov.: **
Zip/Postal: Country:
Phone: ** Email: **
SHIP TO: (if different)
Company/Name: Address:
City: State/Prov.:
Zip/Postal: Country:
Phone: Email:
#2: Product Lines
Task Lamps
R-Shade Models:    
 Quantity:  
R-Shade Line Total:
K-Shade Models:
Quantity:  
K-Shade Line Total:
H-Shade Models:   
 Quantity:  
H-Shade Line Total:
Halogen Models:
Quantity:  
Halogen Line Total:
Base Price Total Cost:
#3: Payment Information
Payment in $U.S. Dollars. 
Note: Sales tax will be charged to Wisconsin Buyer without a tax exempt form on fill at our corporate offices.
Open account, with approved credit!
Cash in Advance
MC  Visa  AM.EXPRESS  Name on card:
Card #:Please call with card Number
#4: Shipping Information
Please send products via:
Your UPS #:
Your RPS #:
If other please state:
Comments:

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