Burks Pickup or Delivery Request Form
Order Supplies or Job Pickup/Delivery

Company and Contact Information:

 

Email:		Contact Name:
Work Phone:		Company:
Street Address:		Zip/Postal Code:

Order Information: Pickup or Delivery? Deliver Pickup

Quantity	Item Description	Boxed Media (Add'l Fee Applies)
		No Yes
		No Yes
		No Yes
		No Yes

Billing Information: 

Burks Facility Management Agreement  (e.g. Printer-Scanner-Copier Solution):	No Yes
Burks Account Number (if you have one):
or Purchase Order Number:
Special Instructions: