PURCHASE ORDER	Date: ___________
Print this form, complete the information and fax to: 712-881-2211

	Your PO No:	____________________		Vendor:	Graham Systems, Inc.
	Company Name:	_____________________			206 N 8th St
	Ordered By:	_________________________			Mapleton, IA 51034
	Phone:	______________   Fax: _____________			Phone: (515) 577-6792
	Email:	__________________________			Fax: (712) 881-2211
		Ship To:
	Attn:	______________________
	Address:	_____________________________
		_____________________________
	City, State Zip	______________________, _____ ________
		Bill To: Same as Shipping
	Attn:	______________________
	Address:	_____________________________
		_____________________________
	City, State Zip	_______________________, _____ ________

Line	Qty...	Part Number	Description.............................................	Unit Price	....Ext. Price
1	.	.	.	.	.
2	.	.	.	.	.
3	.	.	.	.	.
4	.	.	.	.	.
5	.	.	.	.	.
				SubTotal	$
	Payment Details Check            Account No. _________   Credit Card,  Name on Card: _______________  Card No. __________________      Exp. Date:  Mo.____ Yr. ____   6% Sale Tax for Orders Shipped to Iowa Handling Charge $5.00 for packages 1-34 lbs, $7.00 for packages 35-70 lbs.

	Shipping Method:	________________________
	Acknowledge Order By:	___________ to: __________________
	Special Instructions:	__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________