The Hi-Gear Co., Inc.

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Customer PO Number:

** Required Fields are denoted by asterisks

Hi-Gear Customer Number:

** You must supply a valid Hi-Gear Customer Number to process order

Company Name:

Ship To Address Info:

Address Line 1:

Address Line 2:

City:

State:

Zip:

- **

International Info:(Only necessary for Canadian or Mexican shipments !)

Country:

Province or State:

Postal Code:

Bill To Address Info:

Address Line 1:

Address Line 2:

City:

State:

Zip:

International Info:(Only necessary for Canadian or Mexican shipments !)

Country:

Province or State:

Postal Code:

Order Info:

Contact Name:

E-mail:

** You must supply a valid e-mail address to process order

Phone:

ext.

** example ... (800-555-1212)

Fax:

Date:

Orders Shipped Via UPS:

Ground 3rd Day 2nd Day Next Day Other

* Orders will ship Ground unless specified otherwise

If you specified other, please describe ...

Special Instructions:

Payment Terms:

Open Account C.O.D. Credit Card

Card Number: We will contact you for Card Information

QTY

Part #

Description

Cost Each

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