CONFIRMATION OF PURCHASE ORDER

DATE OF ORDER: ______________________
P. O. # (IF APPLICABLE): _______________
BILL TO:                                                                SHIP TO:
____________________________________        ______________________________
____________________________________        ______________________________
____________________________________        ______________________________
____________________________________        ______________________________

PRODUCT: DISCOUNT: ___________________
                      TERMS: ______________________
                      QUANTITY: ___________________
NO CHARGE OFFSET PRODUCT: _________ ($__________) @ RETAIL VALUE.

SYSTEM: NET COST: _____________________
                  TERMS: ________________________

FREIGHT FOR PRODUCT AND SYSTEM: _______________________
SHIP DATE: (Pending credit approval): ___________________________

______________________      ___________________       _________________
Authorized Signature                   Title                                      Date

Please complete and return to ______________________________ Sales Department
FAX # ____-____-_______

THIS ORDER WILL BE HELD UNTIL RECEIPT OF THIS SIGNED FORM.
Thank You.