Order Form ® ® PHONE MAIL FAX ONLINE 800-228-1698 P. O. Box 1047 937-252-8502 or www.southpawenterprises.com 7:30 a.m. - 5:30 p.m. Dayton, OH 45401-1047 937-258-4390 anytime 24/7 Date: Check One:o Past Customero New Customer o Parento Teachero Therapist Customer Number If Known: ________________ SHIPTO: (If different from Bill To:) BILLTO: Name: ___________________________________________ Name ____________________________________________ Company _________________________________________ Company _________________________________________ Address __________________________________________ Address __________________________________________ Must be a street address. We cannot ship to a P. O. Box. City ______________________________________________ City _____________________________________________ State/Province _________________ ZIP ________________ State/Province ___________________ ZIP______________ Country___________________________________________ Country __________________________________________ Phone ( _____ ) ____________________________________ Phone ( _____ ) ____________________________________ Qty. Catalog Number Description Unit Price Total Price If any item on this Order Form, by which Southpaw Enterprises Inc. ("Southpaw") accepts customer's order, is in- correct in any way, please inform Southpaw at once. All products supplied by Southpaw are expressly conditioned $SUBTOTAL on customer's assent to the terms and conditions set forth in our catalog and website, including any such Terms which are additional to or different from the terms of customer's order or any other documents submitted by customer to Southpaw. In the event that any quotation, purchase order, order acceptance, sales form, and/or Please add applicable sales tax $OH ORDERS verbal expression is used which contains terms which are in addition to, different from or inconsistent with those in SHIPPING & HANDLING the Terms, the Terms shall be controlling, and any such additional, different or inconsistent terms and conditions CONTINENTAL UNITED STATES $ of $8 or 14% greater thePlease add shall be inapplicable and are hereby objected to. Receipt and acceptance by customer of goods supplied by South- to your order to cover paw shall constitute acceptance and assent by customer of the Terms, even though such acceptance and assent is shipping & handling not limited to the foregoing method. The Terms are subject to change by Southpaw without notice. NW Territories must call for quote. All $ of $10 or greater theCANADIAN ORDERS* please addothers 21% to your order to cover shipping and handling. CHECK ONE: o Purchase Order No.__________________________________________ Write or call for a shipping quote. $shipped UPS. & Puerto Rico ordersAlaska, Hawaii o Check Enclosedo Money Order TOTAL AMOUNT $ Media Code o o o o Account Number Exp. Date: ______ Security Code: ____________ *CANADIAN ORDERS Print Cardholder’s Name:________________________________ Brokerage charges, GST taxes and duties not included in our prices or shipping and handling. Signature: (X)_________________________________________ © 2013 Southpaw Enterprises Inc.
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