Steele Supply Company 3413 Hill Street St. Joseph, MI 49085 U.S.A.

Tel (269) 983-0920 Fax (269) 983-0970 E-mail order@steeles.com http://www.steeles.com

Order Form

Date:________________

Name:_____________________________________________________

Address:__________________________________________________

City:_____________________ State:___________ Zip:___________

Phone Number:______________________________ Email:______________________________
Quantity Item# Description Price
________ _______ ___________________ _______
________ _______ ___________________ _______
________ _______ ___________________ _______
________ _______ ___________________ _______


Subtotal________________

Shipping________________

Tax (6% In MI only)________________

TOTAL________________

Method of Payment: _____Visa _____Discover _____MasterCard _____Check #___________

Card Number: __________ __________ __________ __________ Expiration_____________ CVV_______

Name on card (if different than above)___________________________________

Billing Address(if different than above)

Address:__________________________________________________

City:_____________________State:___________Zip:___________

Cardholder Signature:___________________________________

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