Boltex Inquiry Form

*CUSTOMER INFORMATION*
Date:
Date Due:
Customer Name:
Contact Name:
Customer Phone:
Customer Fax:
Customer E-Mail:

PURCHASE INFORMATION
P.O. #
Ship Via:
FOB:	Boltex Destination
Freight:	FFA Collect Prepaid 3rd Party Billing
Terms:

Bill To:



Ship To: