collections, inc.

Blank Stock Order Form

SKU Quantity Description Unit Price Extended Price

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Payment Information: Visa Mastercard American Express Exp. ______/______

Credit Card Number ____________________________________________

Authorized Signature __________________________________________

Special Instructions:__________________________________

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Current Dealer Yes No

Dealer ID _______________________________________

Company Name __________________________________

Phone ___________________________________________

Shipping Address ______________________________

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Fax _______________________________________________

Total:

Invoice # ________________________________________

Noteworthy Representative ___________________

Requested Ship Date ___________________________