R & D Sprayers 419 Hwy. 104 Opelousas, LA 70570 337-942-1001 Fax: 337-942-7841 To fax in an order, please fill in the following information and fax to 337-942-7841. Company: _______________________________________________________ Contact: _______________________________________________________ Shipping Address 1: ____________________________________________ Shipping Address 2: ____________________________________________ City: __________________________________________________________ State: _________________________________________________________ Zip Code: ______________________________________________________ Phone Number: _________________________________________________ Fax Number: ___________________________________________________ Credit Card Number: ____________________________________________ Name on Card: __________________________________________________ Expiration Date: _______________________________________________ CCV Number (3 digits on back of card): _________________________ Billing Address 1: _____________________________________________ Billing Address 2: _____________________________________________ City: __________________________________________________________ State: _________________________________________________________ Zip Code: ______________________________________________________ Part # Description Quantity ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ ___________ _________________________________________ ____________ Additional information: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________