Eastern U.S.              Western U.S.
      100 Mc Farland Ave        2545 Brockton, Suite 100
      PO Box 458                PO Box 16080
      Rossville, GA 30741-0458  Austin, TX 78761-6080
      PHONE: 800-241-8950       PHONE: 800-443-6283
      FAX: 800-480-5846         FAX: 800-480-5845
      EMAIL:gasales@gtdist.com  EMAIL:txsales@gtdist.com

DEPARTMENT NAME:_________________________________________________________

Please Circle One:    Federal Govt.    State Govt.    City Govt.    

Billing Address:_____________________________________________________________________

CITY:_____________________ State:___________ ZIP:___________________

CONTACT:__________________ PH:______________ FX:_____________ EMAIL:_______________

Checks processed by (Name on check):________________________________

SHIPPING ADDRESS:____________________________________________________________________

CITY:_____________________ STATE:___________ ZIP:___________________

CONTACT:__________________ PH:______________ FX:_____________ EMAIL:_______________

HEAD OF AGENCY:___________________________________EMAIL:_____________________

SALES TAX: ___ YES ___ NO  FEDERAL TAX EXEMPT: ___ YES ___ NO 

PURCHASE ORDER REQUIRED: ___ YES ___ NO

IF NO PURCHASE ORDER REQUIRED, WHO IS AUTHORIZED TO MAKE PURCHASE:

__________________________  __________________________  __________________________ 

__________________________  __________________________  __________________________

SPECIAL INSTRUCTIONS:_____________________________________________________________

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SHIP VIA:_____________________________________________