Order Form

102 Barnhill Road S.E. • New Philadelphia, Ohio 44663

(330) 364-6627 • Fax (330) 364-1392 • Toll Free (800) 624-9892

A supplier of plastic pipe and fittings for sewer & drain, as well as fresh water supply.

Order Form:

Company Name Account Number

Name E-Mail Address

If you have a current account with Tolloti, you do not need to fill out the rest of this section:

Address Method of Payment

City State Zip We are a (select one)

Phone Fax (please include area/country codes)

Item 1 Qty: Description: Unit Price:

Item 2 Qty: Description: Unit Price:

Item 3 Qty: Description: Unit Price:

Item 4 Qty: Description: Unit Price:

Item 5 Qty: Description: Unit Price:

Item 6 Qty: Description: Unit Price:

Item 7 Qty: Description: Unit Price:

Item 8 Qty: Description: Unit Price:

Tolloti will compute Totals and other cost that may apply.

You May Charge you Purchase with Visa or Master Card :

Name on Card: Card #: Exp. Date:

Notice: This card information is not being transferred encrypted over a secure server. If you are not comfortable with this, you may call or fax us your credit card information. Phone 1-800-624-9892 FAX 1-330-364-1392

Ship To: Ship Via:

Ship To: Additional Comments: