Embassy Vending Order Form


The Vending Machine Company TM

Our Dun & Bradstreet
ID # is
10-205-2516

BBBOnLine Reliability Seal Embassy Vending
1525 Circle
Dr.
Lincoln, NE 68506
phone 1.
402.438.4398 
fax 1.800.839.2412
SSL Certificate Authority


Purchaser's Information: Shipping Address: or [  ] check if same
Name Name
Company Company
Address Address
City City
State State
Zip Zip
Phone Phone
email address fax

 

Quantity Descriptive List of Equipment Ordering Unit Cost Total Cost
       
       
       
       
       
       
       
       
       
 

 

   
       
 

 If you need a liftgate because of no loading dock or forklift add $50.00

   
  Method of Payment:  O Cashiers Check    O Money Order    O Check    O Wire Total  
  O Visa     O MasterCard     O Discover     O AMEX Shipping  
  Credit Card #__________________________________________
Expiration Date_________
(CVV2/CID) the 3 Digit # on back of card next to cc #.  _________
*Grand Total*  
Credit Card Billing Information  
Name___________________________   MI____ on credit card
Billing Address_______________________________________________
Check if billing address same as, [   ] purchaser's address, or [   ] shipping address. 
Purchaser's Signature _X___________________________________  Date  _________
By signing I authorize Embassy Vending to charge my credit card the *Grand Total* for this order.