order form

5 Fisher St. LaPorte, Ind. 46350.........219-326-7788 or 800-348-8809....Fax:219-324-5962

Email: ddijl@diedrichdrill.com

ORDER FORM

Date:		Date Required:

Enter Your Billing Name and Address Here		Enter Your Shipping Address Here

Enter Phone #
Enter Fax #
Payment Options:		Shipping Payment:	Shipping Mode:
	Credit Card	(Check One)	Motor Freight
	VisaMaster Card	Bill	Air Freight
Card Number:		Collect	Federal Express
Expiration Date		Third Party	Service
Credit Card Name		Acct#: (below)	UPS Ground
	COD		UPS 1st Day
Note: We can only accept credit card or COD			UPS Early AM
payments at this time!			UPS Saturday
			UPS 2nd Day
			UPS 3rd Day
			Pick Up