Hose Order Form

Plastic Selections

Hoses Order Form

Please fill out the order form. Orders Under $50.00 are subject to a $20.00 Small Order Charge.

Note to International Customers: ALL International orders are only shipped Collect by Fedex, UPS, TNT, or DHL. International Orders are subject to a $40.00 charge for Nafta Certificate of Origin, and US Customs Invoice Creation.

Please fill out the order form.

Hose Stock #
Inside Dia.
Color
Length

Pieces Needed

Hose Stock #
Inside Dia.
Color
Length

Pieces Needed

Hose Stock #
Inside Dia.
Color
Length

Pieces Needed

Connectors, Clamps, Cuffs, Adapters

Stock #
ID

Pieces Needed

Ship To Address

Name
Company
Street Address

City
State
Zip Code
Country
International Postal Code
E-mail
Telephone
Fax Number
Credit Card Type
Credit Card Number
Expiration Date on Card
Name on Credit Card
Zip Code Statement is Sent To for Address Verification
Purchase Order (if required)

Shipment Type
If Other Please Specify
Other Account # to ship on
Shipment Billing Selection
My Shipping Account Number

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Fasteners
Self Drilling Screws	Carriage Bolts
Self Tapping Screws	Hex Nuts
Set Screws	Lag Screws
Sheet Metal Screws	Wood Screws
Washers	Spring Pins
Threaded Rods	Dowel Pins
Socket Head Shoulder Screw	Taper Pins
Socket Head Cap Screws	Shafts
Metal/Plastics Spacers-Standoffs	Felt Sheets, Discs, Strips, Cords
U Channels	Circuit Breakers
Eyebolts	Spur Gears
Worm Gears	Worm Gears
Gear Racks	Miter Gears
Helical Gears	Tapes- Skived, Adhesive Backed
Springs	Exhaust, Duct, Air, Vacuum Hose