Direct Prepaid Order Form

Customer ID (returning customers)

EIN

Company Name

Telephone

Address

City

State/Province

Zip/Postal

Country

Tax_Exempt Tax_Exempt Yes ( If yes, tax-exempt certificate must be sent to Orders@automatedeleparts.com. Failure to provide tax tax-exempt certificate may result in being charged sales tax. ) No

Quote Number

Order Confirmation Email Address

PO Number

PO Total

Shipping Method Shipping Method Collect Prepay and Add

Carrier

Account Number

Ship to Company Name (if different)

Attn

Address

City

State/Province

ZIP/Postal Code

Special Instructions

Payment Method Payment Method Credit Card ACH/Wire Check by Mail

Option 1 Option 1 A link for credit card payment will be emailed to the order confirmation email address unless specified otherwise.

Option 2 Option 2 Bank payment instructions will be emailed to the order confirmation email address unless specified otherwise.

Option 3 Option 3 Please remit to : 1999 Edison Hwy Suite 13, Bakersfield, CA 93305

Authorized Name

Date

Title