Net-30-Day terms
to well rated firms
and Govt. agencies.
Most
Omnicron orders are placed either by phone or
via purchase orders faxed or mailed to us. You can also use this form to place an order
via our web site.
To place an order and pay with your credit
card, complete this form and your information will be emailed to us. We will
obtain authorization and ship your order. If you have questions or do not feel
secure using this process, you can also call Omnicron at (860)
928-0377
and place your credit card order over the phone. This form is only for
orders placed by and shipped to US addresses. Government agencies and
firms rated 1 or 2 by
D&B can also order via faxed or mailed purchase orders for Net-30-Day terms. Click here for a
printable PDF order form.
Your Name
Company Name
Address 1
Address 2
City
State
Zip Code
Phone Number
FAX
E-mail
URL
Shipping Address — If different from above:
Address 1
Address 2
City
State
Zip Code
Requested Method of Shipment: (you will be charged for the actual shipping
costs)
Ship Via
Is there a PO# for us to reference on this
order:
Purchase Order #
I would like to order the following items from Omnicron:
(Obtain Cost
$ from Price List)
1st Omnicron Item #
1st Item Quantity
1st Item Cost Each $
2nd Omnicron Item #
2nd Item Quantity
2nd Item Cost Each $
3rd Omnicron Item #
3rd Item Quantity
3rd Item Cost Each $
4th Omnicron Item #
4th Item Quantity
4th Item Cost Each $
5th Omnicron Item #
5th Item Quantity
5th Item Cost Each
6th Omnicron Item #
6th Item Quantity
6th Item Cost Each
I would like to pay for this order with my credit Card:
CREDIT CARD INFORMATION:
Credit Card
Cardholder Name
Card Number
Expiration Date
CREDIT CARD BILLING ADDRESS:
Phone Number
Address 1
Address 2
City
State
Zip Code
Do you have comments or questions about this order:
You should print either a copy of this form
prior to submitting it to us,
or a copy of the confirmation page you will see
shortly after clicking
on "Submit Form" button below.
OMNICRON ELECTRONICS
581 Liberty
Highway, Putnam, CT 06260
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