Moss Sales & Service, Inc. Salina, Kansas



I-135&State St.PO Box 2807Salina, KS 67402-2807785-825-8177800-221-8177Fax:785-823-2281www.mosssales.commoss@mosssales.com

ON-LINE PARTS ORDER FORM
To order, please complete all items in the form below. If you have any questions
concerning your request, please do not hesitate to inquire through email or call us at the above numbers.
All items in RED must be filled in!

Date:	Company Name:
Billing Address: Street Address:
City:	State/Prov:	Zip or Postal Code:
Country:
Ship to: Street Address:
City:	State/Prov:	Zip or Postal Code:
Country:

For foreign shipments please enter your address here:

Phone Number:	Fax Number:
First Name:	Last Name:
Title:	Email Address:

MANUFACTURER, MODEL AND ITEMS REQUESTED

Manufacturer Name

Model Number

Serial Number

Item:	Quantity:	Part #:	Description:	Price:
#1
#2
#3
#4
#5
#6
#7
#8
#9

Kansas Tax will be added to your order

Delivery Date:

P.O.#:

PAYMENT INFORMATION

Terms: All net orders must have approved credit. Click HERE for Credit Application form

Payment in $U.S. Dollars.
Open account, with approved credit!
Cash in Advance
MC/Visa (card on record) or
Name on card:
Card #: Exp. Date:

SHIPPING INFORMATION

Please send products via:
Your UPS #:
Your FEDEX #:
If other please state:

Additional Information to assist us in your request: