You may print this form and fax it to 815-288-6790 or you may order online using our secure server .  
Bill To:
Name 
Address 
  
City,ST,Zip 
Day Phone 
E-mail 
 Ship To: (if different from billing address)
Name 
Address 
  
City,ST,Zip 
Qty Part No Name Wgt Option1 Option2 Price Total
               
               
               
Sub Total  
Shipping and Handling  
Total  

Method of Payment: (circle one)
  Check Visa MasterCard

Card No 
Expiration 
Cardholder's Signature 

Print this form, fill in your address and payment information, and send the completed form to us by:

Telephone:
800-648-5429
Fax:
815-288-6790
Mail:
C and N Supply Order Dept
105 S. Peoria Ave
Dixon, IL
61021
Please make Check payable to
C and N Supply Order Dept

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