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Embassy Vending Order Form |
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The Vending Machine Company TM |
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Our Dun & Bradstreet |
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Embassy Vending 1525 Circle Dr. Lincoln, NE 68506 phone 1.402.438.4398 fax 1.800.839.2412 |
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Embassy Vending Order Form |
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The Vending Machine Company TM |
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Our Dun & Bradstreet |
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Embassy Vending 1525 Circle Dr. Lincoln, NE 68506 phone 1.402.438.4398 fax 1.800.839.2412 |
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| 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 |
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| Quantity | Descriptive List of Equipment Ordering | Unit Cost | Total Cost |
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If you need a liftgate because of no loading dock or forklift add $50.00 |
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| 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. |