Parts
Parts Order or Parts Quote Request Form

Please use this form to order parts or to request a quote for parts.

Your Name:
Your E-mail address: Example: yourname@isp.com
Area Code and Phone Number:
If you're outside of the U.S., please enter your country and city codes.		 Examples: 706.863.1011 or 011.39.81.556.7888
Area Code and Fax Number:
If you're outside of the U.S., please enter your country and city codes.
What is this?
P.O. or Quote #:
P.O. #
Quote #  
P.O. Date:
Pump Serial #: 
 Will help ensure correct parts are quoted.
Requested Delivery Date:
FOB:
Shipping Point 
Destination
Preferred Freight Company:
 (FOB Shipping Point/Exworks) 
Billing:
For collect billings, provide a freight compnay account number:
If you selected "Other" for the Billing field, please specify:
Bill To • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Area code and phone number:
If you're outside of the U.S., please enter your country and city codes.		 Examples: 706.863.1011 or 011.39.81.556.7888
Customer ID:  
Ship To (If different from above) • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Area code and phone number:
If you're outside of the U.S., please enter your country and city codes.		 Examples: 706.863.1011 or 011.39.81.556.7888
Customer ID:    
Qty GIW Part No. Description Unit Price
(U.S. Dollars)		 Delivery
(Stock, etc.)*

*Stock means parts will ship in two weeks or less.

Special Instructions or Notes • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Please limit your comments to 60 characters per line below. If you need to send a longer message, e-mail parts@giwindustries.com.