image
image
image
image


Purchase Order / Request Quotation:

Thank you for visiting our website.
Please complete this form to purchase our products or request a price quote.


   
 
 
   
Company Name:
Bill to Address:
City:
State:
Zip Code:
   
Ship to Address:
City:
State:
Zip Code:
   
Purchaser Name:
Phone Number:
Fax:
Email Address:
   
Ship Via:
Expected Delivery Date:
Purchase Order Number:
Credit Card:
Credit Card Number:
Name on Card:
Expiration Date:
Taxable Purchase:
IL Tax Exempt Number:
   
  Quantity Part Number Description Price Each
1
2
3
4
5
6
7
8
9
10
11
12
   
Special Instructions:
 
The information you provide on this form is only used by the employees of Midwest Valve & Fitting, Inc.
We don't provide it to anyone else under any circumstances.


 


Midwest Valve and Fitting
P.O. Box 517 • New Lenox, Illinois 60451 • Phone (815) 727-9339 • Fax (815) 727-9430



image