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HOSE LINE
6060 San Fernando Road
Glendale, California  91202 		Hose Line Corporation Phone:  (818) 547-3010
Fax:  (818) 547-3339
Sales@HoseLine.Net

CUSTOMER ORDER & AUTHORIZATION
DATE:

 REF PO NUMBER:
BILLING ADDRESS
COMPANY NAME:
NAME:
PHONE:
FAX:
ADDRESS:
CITY:
STATE + ZIP CODE:
COUNTRY:		 SHIPPING ADDRESS
COMPANY NAME:
NAME:
PHONE:
FAX:
ADDRESS:
CITY:
STATE + ZIP CODE:
COUNTRY:
[  ] WILL CALL. [  ] GROUND FEDEX UPS [  ] OCEAN [  ] DROP SHIP UPS FEDEX ACCT FOR BLIND SHIPMENTS:
PAY BY [  ] VISA [  ] MASTERCARD [  ] AMERICAN EXPRESS [  ] BUSINESS CHK [  ] MONEY ORDER
AMEXACCOUNT NUMBER & EXPIRATION DATE:
NAME, TITLE & SIGNATURE:
SEE HOSELINE.NET WEBSITE FOR TERMS & CONDITIONS. PRINT THIS FORM TO PAPER. LOS ANGELES, CA SALES TAX IS 9.75% AS OF JAN 2010. FOR RESALE CERTIFICATE, SEE OUR RESOURCES PAGE.
PART NO. DESCRIPTIONQTY. UNIT PRICETOTAL
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
SUBTOTAL  
No tax outside California. SALES TAX  
FREIGHT
 
GRAND TOTAL