PSM Solutions
4501 New Bern Ave., STE 130-#332
Raleigh, NC  27610-155-
(919) 342-0376 (888) 806-0617 FAX (919) 342-0379
 
 
Order Form
 
Contact Name:    Purchase Order #: 
 
Contact E-Mail Address:  Phone #  Fax # 
 
Company: 
 
 SHIP TO:
 
Street Address: 
 
 
City  , State  , Zip   
 
Country 
 
BILL TO: (or billing address of credit card):
 
Street Address:
 
 
City  , State  , Zip   
 
Country 
 
Credit Card Number:  Expiration Date:   
 
        Mastercard          Visa         American Express         Discover
 
Name as it appears on Card: 
 
Signature: (if faxing form)______________________________________________________________
 
 
Shipping Preference: 
 
 Ground      Overnight      2nd Day      3 Day
 
Order Items: 
 
Line      Quantity Item Description
 
1.         
2.         
3.         
4.         
5.         
 
Comments:
 
  
 
 
Thank you!