Shelmarc Carpet Mills, Inc.

Contact
*Account Number:

Company:

First Name: Last Name:

Phone #: Ext. #:

Fax #:

E-mail:

Bill To:

Name:
Address 1:
Address 2:
City:
State:
Zip Code:

Ship To:

Name:
Address 1:
Address 2:
City:
State:
Zip Code:

Order Information:

P.O.#:
S/M:
Ship Via:
PPA / Collect / 3rd Party:
*If 3rd Party bill, then please include address:
Sales Agent: (REQUIRED)

Product #1

Style:
Color:
Size:

Product #2 (*If necessary. Otherwise leave blank)

Style:
Color:
Size:

Product #3 (*If necessary. Otherwise leave blank)

Style:
Color:
Size:

* All customers must have an account number to place orders. If you do not have an account please contact Shelmarc Customer Service to have one set up for you (888-504-3100).