To order, please print and fax this order form to  213-226-4690
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Bill To:
Company  
Address  
   
City, ST, Zip  
Contact  
Phone  
Email  
Ship To: (if different from billing address)
Company  
Address  
   
City, ST, Zip  
Contact  
Phone  
Email  
 
Qty Part# Description Each Total
         
         
         
         
         
         

Note:

If you want to pay us Net 30 days, please fax along your credit references.

Purchase Order Number:                            

 
Sub Total  
Shipping  
 Total  
 Sales tax if applicable  
 Please Enter Total Payment  
Method of Payment:(circle one)
 Visa 
 MasterCard   AMEX   Check 
Card No Please call with credit card number!
Expiration  
Billing ZIP for card  
Cardholder's Signature  
Fax: (213) 226-4690
 Mail: Safna Engineering
Attn. Steve Eszeki
450 S. Lone Hill Ave.
San Dimas, CA 91773

Print this form, fill in your shipping and payment information, and send the completed form to us.
Telephone: Steve 
( 800 ) 509-8265
or 213 798-0903


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