Order Form

Public Images Network
1154 Larc Lane, Toledo, Ohio 43614
phone (419) 380-4049 fax (888) 273-1623 Federal I.D. Number 31-1072025

After you fill out this form

• Submit via email by clicking the submit button below,
• Print and fax to the above number, or
• Print and mail to the above address
  
  Shipping Address
  
  Name:
  Organization:
  Address:
  City:
  State:
  Zip Code:
  Phone Number: --
  
  Billing Address
  
  
  Name:
  Organization:
  Address:
  City:
  State:
  Zip Code:

Purchase Order Number:

Tax Exempt Number: please make sure to include this number when applicable
-
when ordering T-shirts please remember to include size

Item Qty Cost $

Item Qty Cost $

Item Qty Cost $

Item Qty Cost $

Item Qty Cost $

Subtotal $

Shipping $

Under $20, add $6
$20-$50, add $8
$51-$100, add $11
Over $100, add $16

Total Amount of Order $

Email address

I am a repeat customer of the Public Images Network/Ohio Public Images Yes No

Comments: