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Wikco Industries
9330 Thornwood Drive  Lincoln NE 68512
Fax 402-464-2070
Phone (800) 872 - 8864

E-mail = info@wikcoind.com  
Please Fax, e-Mail, or Mail This Order Form
Order Form
FIRST NAME: ________________________________
LAST NAME: ________________________________
COMPANY NAME: ________________________________
SHIPPING ADDRESS: ________________________________
CITY: ________________________________
ZIP: ________________________________
PHONE: ________________________________

ITEM 1: ________________________________
QUANTITY 1: ________________________________
AMOUNT 1: ________________________________
ITEM 2: ________________________________
QUANTITY 2: ________________________________
AMOUNT 2: ________________________________
ITEM 3: ________________________________
QUANTITY 3: ________________________________
AMOUNT 3: ________________________________
ITEM 4: ________________________________
QUANTITY 4: ________________________________
AMOUNT 4: ________________________________

If paying by check or money order, please enclose payment with your order. If paying by credit card, please include the credit card number below, along with a signature in the signature box. 
[  visa,master card,discover,american express ]
TYPE OF CREDIT CARD:________________________________
CREDIT CARD NUMBER: ________________________________
EXPIRATION DATE: ___________________  Security Code:_____________________

Please fill out the mailing address if it is different from your shipping address, and/or if the shipping address is different from the billing address on the credit card you are using. When you fax or mail the order form, please sign this sheet in the appropriate box below when paying by credit card.

Please note: by signing this order form you are agreeing that your credit card billing address is either the same as the shipping address, or is the mailing address listed below. This authorizes Wikco Industries to ship your order to the shipping address listed on this form.

MAILING ADDRESS:________________________________
CITY: ________________________________
STATE: ________________________________