WPCI EBT SUPPLY ORDER FORM
Print this form and fax to WPCI at 308-632-6448 or phone
directly to 1-800-682-5176 attn: Shipping & Receiving.
Date:________________P.O.#____________________FED ID____________________
| Ship To: Company Name: |
- | Attn: | - |
| Shipping Address: | - | Title: | - |
| City/St/Zip: | - | Phone | - |
| Bill To: Company Name: |
- | Attn: | - |
| Billing Address: | - | Title: | - |
| City/St/Zip: | - | Phone | - |
| Special Instructions:
|
| Product Description | Product Number | Quantity Ordered |
Unit | Unit Price | Extended Price |
| Bottle .10 Certified Solution 500ml | ALC-10 | - | Ea | $10.00 | $ |
| Bottle .02 Certified Solution 500ml | ALC-02 | - | Ea | $10.00 | $ |
| Bottle .04 Certified Solution 500ml | ALC-04 | - | Ea | $10.00 | $ |
| Evidence Tape 100/pk | ET-002 | - | Pk | $10.50 | $ |
| DOT Alcohol Testing Forms 100/pk | DOT-01 | - | Pk | $25.00 | $ |
| Non-DOT Alcohol Testing Forms 100/pk | NDOT-02 | - | Pk | $30.00 | $ |
| Guth Simulator Mouthpieces 25/pk | SMP-5401 | - | Pk |
$11.50 | $ |
| Phoenix Mouthpieces 100/pk | PXMP-0001 | - | Pk | $35.00 | $ |
| PBA Mouthpieces 100/pk | PBMP-0100 | - | Pk | $40.00 | $ |
| PBA Single Ply Paper 1/Roll | SPP-001 | - | Roll | $2.25 | $ |
| PBA Three Part Paper 1/Roll | SPP-003 | - | Roll | $3.00 | $ |
| Portable Printer Ribbon | PRB-01 | - | Ea | $10.50 | $ |
| ADS Mouthpieces 100/pk | ADS-0100 | - | Pk | $40.00 | $ |
| Alco Data Thermal Printer Paper | TPP-001 | - | Roll | $2.00 | $ |
| Alco Data Cylinder Mouthpieces 100/pk | TMP-001 | - | Pk | $28.00 | $ |
| Alco Data Disk Saliva Trap Piece | AAMMTOP | - | Ea | $0.28 | $ |
| Prices subject to change without notification. | SUB-TOTAL | $ | |||
| 30% Re-Stocking Fee | S&H ($4.50 Min) | $ |
FAX TO: 308-632-6448 PHONE: 800-682-5176
