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KNIGHTS OF COLUMBUS

FORM NO. 1 (3/07)

SUPPLY DEPARTMENT

DATE

REFER TO CONTROL NO.

78 MEADOW STREET, NEW HAVEN CT 06519-1759 (203) 752-4214 or (203) 752-4451 FAX 1-800-266-6340 U.S. and Canada

NO.

REQUIRED INFORMATION – PRINT CLEARLY FOR MAILING LABEL NAME

TITLE

STREET OR P.O. BOX NO. (AVOID P.O. BOX UNLESS NECESSARY)

COUNCIL # ASSEMBLY #

GEN. AGENT #

CIRCLE #

FLD. AGENT #

PLEASE PRINT CHARGE TO (REQUIRED)

CITY

STATE/PROVINCE

DAYTIME TEL. # ( FAX # (

ZIP/POSTAL CODE

PRINT ABOVE NAME & NO. OF COUNCIL ASSEMBLY AGENCY OR CIRCLE

)___________________________________

)_____________________________________________

CITY

STATE/PROVINCE

STATE CODE

ZIP/POSTAL CODE

SIGNATURE REQUIRED (FS, GK, FN, FC, CC, CS, NOTARY, GA or FA)

TITLE (REQUIRED)

ALL PRINT JOB ORDERS MUST BE ON A SEPARATE FORM 1 WITH SAMPLE ATTACHED QUANTITY

ITEM/ FORM NUMBER

SHIPPED

UNIT PRICE

DESCRIPTION

I F N E C E S S A RY

Subtotal

Need by Date: Picked By

Packed By

Date Shipped

PAYABLE IN U.S. FUNDS — Make check or money order payable to: Knights of Columbus Supreme Council, 78 Meadow St, New Haven CT 06519-1759

CT Residents add 6% sales Tax CANADIAN residents add 6% GST NB, NF, NS& LAB residents add 14% HST

Check/Money Order No. ___________ Amount __________ OR charge it to your Mastercard M or VISA M IF CHARGING TO COUNCIL, AGENT, ETC. DO NOT FILL OUT CREDIT CARD BOX

MMMMMMMMMMMMMMMM Expiration Date: Month __________________ Year ___________ ___________________________________________________ SIGNATURE REQUIRED for credit card orders

1

TOTAL

OFFICE USE ONLY

Shipping and Handling TOTAL AMOUNT

EXPLANATION CODE CI — CANNOT IDENTIFY/UNKNOWN ITEM O — ITEM IS OBSOLETE R — PLEASE REORDER – ITEM IS NOW OUT OF STOCK BO — ITEM IS ON BACKORDER AND WILL BE SHIPPED ASAP S — SUBSTITUTE PROVIDED V — SPECIAL ORDER – VENDOR ITEM SHIPPED SEPARATELY

ORDER BILLING MEMORANDUM – BILLING COPY

FAX YOUR ORDER • 1-800-266-6340 (US AND CANADA) • DO NOT MAIL FAX ORDERS DO NOT REMOVE THIS TAB — KEEP LAST PAGE ONLY FOR YOUR RECORDS


Purchase Requisition Form 1