FAX ORDER SHEET         Print This Page

Print, fill out, then fax this completed order sheet to Patroller Supply at (303) 295-9922.
Email sales@PatrollerSupply.com or call us at (303) 507-0222 with any questions.
First name:  ______________________ First name:  ______________________ Last name:  ______________________ Last name:  ______________________ Address:  ______________________ Address:  ______________________ Address 2:  ______________________ Address 2:  ______________________ City:  ______________________ City:  ______________________ State & zip:  ______________________ State & zip:  ______________________ Country:  ______________________ Country:  ______________________ Ship this order to the billing address?  Yes      No Phone #:  ______________________ Retail order:  Fax #:  ______________________ Pro-Form order:  Email address:  ______________________ Request for quote:    Pro-Form RFQ:     Order #: __________ Purchase order #: _________________ Date: __________               ITEM # ITEM NAME UNIT PRICE         QTY.    TOTAL      1) _____________    ______________________________________ ________   x ____ = ___________ 2) _____________    ______________________________________ ________   x ____ = ___________ 3) _____________    ______________________________________ ________   x ____ = ___________ 4) _____________    ______________________________________ ________   x ____ = ___________ 5) _____________    ______________________________________ ________   x ____ = ___________ 6) _____________    ______________________________________ ________   x ____ = ___________ 7) _____________    ______________________________________ ________   x ____ = ___________ 8) _____________    ______________________________________ ________   x ____ = ___________ 9) _____________    ______________________________________ ________   x ____ = ___________ 10) _____________    ______________________________________ ________   x ____ = ___________  Payment method: Taxable total: = ___________ Check   Bank wire   Credit card Colorado resident %7.72 state tax: + ___________   Shipping: + ___________  Name on credit card:  ________________ Sub total: = ___________ Card/routing number:  ________________ Order adjustment (+ or -): ___________ Expiration date month:  _____  Year: _____ Invoice total: = ___________ CCV number *:  _____    * The three digit card code verification (CCV) number can be found on the back of most credit cards, but for AMEX cards the four digit code is on the right front side of the card