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3860 N. PalmerSt.  Milwaukee, WI. 53212  Voice 414.962.6500  Fax 414.962.5780
www.ruemelin.com...........sales@ruemelin.com
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Order Form
If you have any questions concerning your request, please do not hesitate to
inquire through email or call us at the above numbers.
All items in RED must be completed to process a order!
Date:.  Company Name:.
Billing Address:
Street Address:.
City:.  State:.  Zip:.
Ship to:
Street Address:.
City:. State:. Zip:.
For foreign shipments please enter your address here, with broker name:
Phone Number:.  Fax Number:.
First Name:.  Last Name:.
Title:.  Email Address:.

MODEL AND/OR ITEMS NEEDED
For NEW equipment please describe item(s)  below, including model number and quanity:

For REPAIR parts please complete below:
Model Number. Serial Number.
Additional Information to assist us in filling your order:

Item: Quantity:  Part #: Description:
#1
#2
#3
#4
#5
#6
#7
#8
#9
 Delivery Date Requested:.

PAYMENT INFORMATION
Terms: All net orders must have approved credit.Click HERE for Credit Application form
How will you be making payment?($U.S. Dollars)
Open account, with approved credit!
Cash in Advance
Quoted price is: .
P.O Number is: .

SHIPPING INFORMATION
Please send products via:
Your UPS #:.
Your FEDEX #:.
If other please state:.
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& Web Centers of America, Inc