CUSTOMER NAME AND ADDRESS SHIP TO ADDRESS                   CONTACT PERSON PHONE FAX    ( _ _ _) _ _ _ - _ _ _ _ ( _ _ _) _ _ _ - _ _ _ _ ITEM DESCRIPTION QTY UNIT PRICE AMOUNT                                                                         All prices quoted are F.O.B. Edgewater, Florida. Sales tax will apply only to orders shipped to Florida locations. Fax This Form to (386) 785-0003 TOTAL    Allied Time use only: SHIPPING    TAX - FL ONLY    TOTAL

PAYMENT INFORMATION:         Type of card (Circle One) FAX CONFIRMATION NAME ON CARD GOOD THRU   AUTHORIZED SIGNATURE DATE