Purchase Order

(to be send by fax)
You can print out the form below as a blank form, then fill it out by hand and fax it to us, or you can fill out this form on your screen and then print it and fax it to us.
P.O. Number: 
Requested By (First & Last Name): 
Date: 
Bill To: Ship To:
Address:  Address: 
City:  City: 
State:     Zip:  State:     Zip: 
Country:  Country: 
Contact Name:  Contact Name: 
Phone:  Phone: 
Fax:  Fax: 
Terms: Credit Card, or Pre-Pay
SKU # Product Description Qty Unit Price $ Ext. Price $
Buyer's Signature                                         Sub-Total:
Shipping:
Total:

Copyright © ExclusiveWholesaler.com. All rights reserved.

Phone:  +630-536-6241        Fax:  +630-961-3155

Credit Card Authorization

(to be send by fax)


Please complete the following with your name and address as it appears on your credit card. It is important that this information is correct, as we verify all information with the credit card company for your safety.

You can print out the form below as a blank form, then fill it out by hand and fax it to us, or you can fill out this form on your screen and then print it and fax it to us. It is up to you. Both ways, are the safest ways to send your personal and credit card information to us, or to any other trusted party.
Cardholder's First & Last Name: 
Billing Address: 
City:     State:     Zip: 
Country: 
Purchase Order Number: 
Visa      Mastercard 
Credit Card Number:     Expiration Date (mm/yy): 
Company Card (yes/no)           Personal Card (yes/no) 
By signing below, I authorize ExclusiveWholesaler.com to charge my credit card
$   plus applicable shipping charges.
Cardholder's Signature                                                            Date (mm/dd/yyyy): 
ExclusiveWholesaler.com Office Use Only

Invoice Number                                 

  Approved Date                                   

Amount Charged $                           

  Charged By                                       

Input Date                                          

  Sent By                                             

Copyright © ExclusiveWholesaler.com. All rights reserved.

Phone:  +630-536-6241        Fax:  +630-961-3155