Thank you for visiting our web site and using our online Product Ordering
and Quote Request Services. Simply fill out all appropriate fields and make sure that the minimum information (*) is provided. After the form is completed, please print out a copy for you records and then click on the submit button. If you would like to fax your order please complete and print out this form and fax it to (858) 578-4633. You may also mail your order to INTEC Wilson Mohr, Inc.,
P.O. Box 12506, La Jolla, CA 92039 USA. To order by phone, call us at (858) 578-7887, or toll-free (888) 464-6832 within the continental USA.


   Company Name

 *
First Time Customer    Yes    No
If Yes, Company Type  
If No, Customer #  

   Ship To:

 Address
Address
City
State / Province  
Zip / Postal Code  
Country  
   Bill To: (Leave the following blank if the information is the same as above. )
Address
  Address
City
State / Province
Zip / Postal Code
Country
Ordered By *
Phone *
Fax *
Email
Requested Ship Date
Partial Shipment
Is Ok Is Not OK
Shipping Method
Standard Three Day
Two-day Overnight
Freight Insurance
Yes No
Freight Prepaid
Yes No
Shipping Tag Notes

Quote Request   Purchase Order # 

Product / Part # Description / Comments Qty

Payment Terms
Net 30 Days
(with open line of credit)
Prepayment COD
Credit Card Letter of Credit
Credit Card Info Master Card VISA Discover
  American Express  

Credit Card #

  
Card Security Code (CVV/CVC) 
Expiration Date (MM/YY) 
Cardholder's Name  
Cardholder's Zipcode  
 
Before sending your order, please use your browser to print or save the file for your records.
INTEC Wilson Mohr will fax an acknowledgment, with pricing and availability information, upon receipt of your order or quotation request. All orders are placed in accordance and agreement with INTEC Wilson Mohr's Terms of Sale.