FAX ORDER FORM

EAST COAST GLOVE & SUPPLY, INC.        FAX ORDER FORM           RETURN HOME
                                                                 Fax To: (631) 471-6574            800 360-8809
                   Shipping Information
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Name                                                                                                 Phone Number

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Company Name Fax Number

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Street Address (Shipping Address) E-Mail

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City/State/Zip Code

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                Ordering Information

QTY.	ITEM NO:	DESCRIPTION	AMOUNT	AMOUNT TOTAL










			SUB TOTAL
		SHIPPING CHARGES
		TAX EXEMPT BUSINESSES AND MUNICIPALITIES MUST SUPPLY TAX EXEMPT FORM	8.625% TAX NY STATE ONLY
			TOTAL AMOUNT

PLEASE SUPPLY YOUR EMAIL ADDRESS __________________________________________

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