Date________________________________ Order Submitted By:____________________________________

Purchase Order No.__________________________________

Ship To:	Bill To:
Company__________________________________	Company__________________________________
Name_____________________________________	Name_____________________________________
Address___________________________________	Address___________________________________
__________________________________________	__________________________________________
City______________________________________	City______________________________________
State_________________Zip__________________	State_________________Zip__________________
If TN State, specify________________	If TN State, specify________________
Tax Exempt No._________________________	Tax Exempt No._________________________

Quantity	Item Number	Description	Unit Price	TOTAL

Subtotal   Shipping & Handling   Sales Tax (TN Only)   TOTAL

For Office Use Only:
Order Received By:________________________________________ Date:_____________________________