Circle K Carts Fax / Mail Order Form
Please fill out all fields as complete as possible.
Fax to:
Phone: 		402-645-5061
402-645-5060 		Mail to: Circle D Mfg. Co. LLC
103 N. 6th Strret
Wymore, NE 68466
Contact Information
Contact Name: ___________________________________________________

Business Name: ___________________________________________________

Phone Number: ___________________________________________________

Alternate Number: ___________________________________________________

Fax Number: ___________________________________________________

Billing Information
Billed to Name: ___________________________________________________

Address: __________________________________________________________________

City: ________________________________ State: ___________ Zip: _________________

Shipping Information
(If different from above)
Billed to Name: ___________________________________________________

Address: __________________________________________________________________

City: ________________________________ State: ___________ Zip: _________________

Order Information
Desired Ship Date: ______________________ Purchase Order #: ____________________

Items to be Ordered:

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Please attach purchase order, additional list of Items and/or other questions or comments.