EFTA01221762.pdf

DL M PlaStics DJM Plastics Ltd dba DLM Plastics 1530 Harvard Avenue Findlay, OH 45840 Phone: 419-424-5250 Fax: 419-423-0849 Authorization to Charge Credit Card Date: 7/14/2015 Attention: Ann Rodriquez Company: ONE TIME SALE -LININGS RE: PURCHASE ORDER Rodriquez, Ann DLM Account It: 5026.003 Thank you for your above-mentioned purchase order Since you have requested to pay for this order with your credit card, this form must be filled out and signed BEFORE we can proceed with your order. BILLING INFORMATION SHIPPING INFORMATION (the address at the e c rd bills to) (we cannot ship to a PO Box) Name as it appears on credit card Name: 453£,LIC- 6+, 77mms;, Billing Address: City, State and Zip Address: City, State and Zip 1RopicAl Sivp;Apet I Code: Contact Telephone Code: Contact Telephone 7505 N W infei-WA ttrivui Number Number: Mgt12 3J 7R Credit Card Type: c= at= Credit Card Number: Expiration Date: Security Code:a_(Visa/MC three digit code on back or American Express lour digit code on !front) DJM Plastics is authorized to immediately charge the following amount to the above account number: U.S. Dollars Descnption Material: $2,182.36 12 Feet WIde x 300 Feet Long Flat Sheet Pond Liner In 40-mil Black CWPE Shipping 8 Handling: $560.57 Shipping & Handling to: 33178 Tax: $0.00 n/a Other S0.00 n/a Total to be Charged: 32,742.93 Total for All Items Listed Above It is agreed that the material will be shipped, Within five (5) business days from receipt of payment It is further agreed that shipping & handling rates are sometimes estimated and may vary slightly from the amount quoted and discrepancies will be billed separately. NOTE: Prices shown do NOT include any cross-bord es-andfees as tai are pa le by the recipient directly to the freight carrier PRODUCTS DESCRIBED HEREIN ARE CUST E AND Tlf Signature of Cardholder: Date: (FOR INTERNAL USE ONLY) Authorization Number DLM Order Number: Processed Dy. Date EFTA01221762