Pilsen Imports - Parts: Request for Parts Quote/Order/FollowUp

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Request Quote / Order / Follow Up

Please fill out the form with as much information as possible and click on the submit button at the bottom of the form.

Contact information:

*Required

	*Your Name:
	Your Company Name:
	*Phone Number:
	Fax Number:
	*E-mail Address:
	*Preferred Response Method:
	*Purpose of Contact:
	Purchase Order Number:
	Quote Number:

Sold to:

	Company Name:
	Attention:
	Address 1:
	Address 2:
	City:
	State/Province:
	Country:
	Postal/Zip Code:

Ship to:

	Company Name:
	Attention:
	Address 1:
	Address 2:
	City:
	State/Province:
	Country:
	Postal/Zip Code:

	Carrier of Shipment:

	Less than 50 lbs:
	Greater than 50 lbs:

	Preferred Carrier:
	Preferred Carrier Account No.:

		Notes:

Machine:

	Machine Model Name:
	Machine Serial Number:
	N/C Type:

Order:

	Part Number	Part Name	Qty.	Price
1.
2.
3.
4.
5.
6.
7.
8.

Comments:

Thank you for your request. If you have any questions, please contact:

Nick Daniele
Parts Support Specialist

Pilsen Imports, Inc.
3985 Virginia Avenue
Cincinnati, Ohio 45227
phone: 513-271-3380 ext. 114
fax: 513-271-8629
cell: 513-477-0995
E-mail: ndaniele@pilsenimports.com

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