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:

*Company Address:

*Contact Name:

*Contact Title:

*Phone Number:

*Email Address:

*Website:

Product Information

*Part Number(s):

*Price Each:

*Quantity per item:

*Need by Date:

End Use Description

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

Business type:

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

Signature

*Name/Title:

*Date:

Ship To:

*Contact Name/Title:

*Contact Email:

*Company Name:

*Street Address:

*City:

*ShipState

Zip Code:

*Country:

*Shipping Method:

Your F/C

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.

*Shipping Type:

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