ESSEX BRASS CORPORATION

Please fill out this form and then press the "submit" button and your order
will be sent to Essex Brass

ESSEX BRASS CORPORATION PHONE: 586.757.8200

FAX: 586.757.8257

All new customer orders over $200.00 must pay by Visa or MasterCard - We will contact you for credit card information		F.O.B. WARREN, MICHIGAN
INVOICE TO:		SHIP TO:
Name:*		Name:*
Acct. #		Acct. #
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
		Tag:
Ordered by:*		Title:
Phone Number:(xxx-xxx-xxxx)*		Order Number:*
Ship:		Ship via:
Pay by:*		E-Mail Address: (for order confirmation)*