Mill Name

Style Name

Color Name

Amount of Yardage /
Square Footage
Needed

Amount of Flooring
Per Square Yard /
Square Footage

Enter Sub Total

CA. Residents Add
7% Sales Tax

Enter Total

Name

Address

City

State

Zip Code

Shipping Address: Any facility with forklift or manpower / Non Residential

Name of Business / Facility / Name

Address

City

State

Zip Code

Business / Facility Hours to Receive Freight

E-Mail Address

Telephone Numbers

Home

Work

Cell

Pager

Credit Card

Visa

Master Card

Credit Card Number

Expiration Date

Enter Exact Name As It Reads On Your Credit Card

First Name

Middle Initial

Last Name

Zip Code That Your
Credit Card Company
Bills You At