Company: _____________________________________ Date: __________________ Ship to: _____________________________________       _____________________________________ Date required: __________________   _____________________________________       _____________________________________     Contact: _____________________________________     Title: _____________________________________     Phone: _____________________________________  Method of payment: FAX: _____________________________________ COD Prepay

Part No. Description Price Qty. Total                                                   Subtotal   CA 8.25%   COD charge   Total

Internal Use Only   Order#:   Date Rcv'd:   Initials:

Please specify Ground, Air, or Nextday shipping or supply your Fedex shipper number. Shipping methods requested will be charged the appropriate fees. California residents add 8.25% sales tax. Add $7.00 for COD orders. Please allow 2 - 3 weeks for delivery. You can place your order by FAX at 818-991-1360 or Phone at 818-991-0360 or Mail this form to: 360 Systems Attn: Customer Service 31355 Agoura Rd Westlake Village, CA 91361

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