PO Form

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Vender:

Phone

FAX:

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Ship To:

Phone

FAX:

Placed by:

Terms:

Ship Via:

P.O.#

Confirmation #

Ordered:

Required:

Completed:

Quantity	Items#	Description	Tax Exemp	Unit Price	Discount	Extended
2	R235	1.0 CT ANN BAND		$650.00	0%	$1,300
2	R235	1.0 CT ANN BAND		$650.00	0%	$1,300

Special Notes:

Subtotal:
$1300.00
Tax:
$0.00
S/H:
$0.00
Total:
$1300.00
Paid:
$0.00
Balance:
$1300.00

Paid On:

Method:

Amount:

Transaction #:

Expires:

Authorization:

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