Acceptable forms of payment

Upon Completion/Submission of this form you will be contacted by Brandstrom Instruments Finance/Administration Manager for your credit card information. Do not include any credit card information on this form.

  • Purchase Order (Terms Net 30)
  • Business Check (drawn on a US bank)
  • ACH, Wire or Paymode-X
  • Major Credit Cards

To initiate a credit card payment:

Purchase Order # (if none is supplied, we will assign our own number):

Contact Information:

*Company Name:

Ship To:

*Contact Name/Title:
*Company Address:
*Contact Email:
*Contact Name:
*Company Name:
*Contact Title:
*Street Address:
*Phone Number:
*City:
*Email Address:
*State:
*Website:
Zip Code:

Product Information

*Part Number(s):
*Country:
*Price Each:
*Shipping Method:
*Quantity per item:
Your F/C
*Need by Date:

If you do not have a Freight Collect carrier account, Brandstrom Instruments, Inc. will bill shipping/duties/VAT/tax charges to your credit card and provide package tracking reference information and a credit card receipt upon shipment.

End Use Description

Is the use military in nature? (Must select one.)

*Shipping Type:

*Describe what the above specified products will be used in:
 

Signature

*Name/Title:
*Date:
*Confirmation: I understand that by checking this box and typing my name & title above, I am signing this document electronically.