1062 Johnsonburg Rd.
St. Marys, PA 15857
Phone: 814-834-7881
Fax: 814-834-9066

sales@indus-sales.com

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Request for Quote/Order Form/Request Information

You may use this form to either request a price quote, order products (existing customers) or request more information.

Please make your selection from the list below. Providing as much information as possible will allow us to complete your request as quickly as possible.

If you prefer to fax this form or keep a copy for your records, print a copy after you have completed the form but before you hit the Send button.

1. Please select:

2. Purchase Order #: (for orders only)

3. Contact Information: (*denotes required fields)

* Name:
Company/
Institution:
Address 1:
Address 2:
City:
State:
Zip Code:
*Telephone:
Fax:
* Email:
Best time to contact me:
Please contact me via:

4. Product Information

Product
Code
(optional)

Description

Quantity

Notes
Item 1:
Item 2:
Item 3:
Item 4:
Item 5:
Item 6:
Item 7:
Item 8:
Item 9:
Item 10:

5. Additional Notes:

6. Send Request/Order:

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