${input_25_6}

${input_25_7_2},

${input_25_7_3},${input_25_7_4},${input_25_7_5}

Phone :

PURCHASE ORDER

 

P.O. # ${input_25_3}

ORDER DATE: ${input_25_4}

VENDOR

${input_25_12},

${input_25_13_2},

${input_25_13_3},${input_25_13_4},${input_25_13_5}

Phone :

SHIP TO

${input_25_67}

${input_25_68}

${input_25_69_2}

${input_25_69_3},${input_25_69_4},${input_25_69_5}

       

 

SHIPPING SERVICE

SHIPPING METHOD

DELIVERY DATE

${input_25_56} ${input_25_57} ${input_25_58}

 

 

 

Quantity

Item #

Description

Unit Price

Line Total

${input_25_22} ${input_25_23} ${input_25_24} ${input_25_25} $0.00

 

Subtotal

$0.00

Sales Tax

${input_25_53}

Shipping Charge

${input_25_59}

Order Total

$0.00

 

 

__________________________________

Vendor Signature

 

__________________________________

Customer Signature