Print and Fax Sales Order Form

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Name _____________________________________________________________

Company __________________________________________________________

Phone  ____________________________________________________________

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ITEM 1

Qty ____      Product Code or Description _________________________________

Packaging:   __ Bulk     __ Drum     __ Keg     __ Pail

                     __ Case/Gallons     __ Case/Quarts     Other ____________________
__________________________________________________________________

ITEM 2

Qty ____      Product Code or Description _________________________________

Packaging:   __ Bulk     __ Drum     __ Keg     __ Pail

                     __ Case/Gallons     __ Case/Quarts     Other ____________________
__________________________________________________________________

ITEM 3

Qty ____      Product Code or Description _________________________________

Packaging:   __ Bulk     __ Drum     __ Keg     __ Pail

                     __ Case/Gallons     __ Case/Quarts     Other ____________________
__________________________________________________________________

Comments _________________________________________________________

__________________________________________________________________

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Prices do not include applicable state or federal taxes and fees.
F. O. B. Chelsea or free delivery in our normal delivery
area with orders of $150. Prices change without notice.

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Fax Sales Order Form To (617) 889-6422

To Order by Phone, Call 1-800-BUY-BURKE