USP Media & Supplies Order Form – US Micro Solutions

Ordering Information

This form is for current customers of U.S. Micro-Solutions. If you are not a current customer, we will request additional information to create an account for you with this order. Orders are shipped either Standard Overnight or Express depending on the date and time needed. Orders received after 3:00 p.m. will be shipped the next business day.

Are you a Current Customer?*

Yes
No

Company Name*

Phone Number*

Please provide the additional requested information to create an account with your order.

Name*

First Last

Company Name*

Principal Contact*

First Last

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Alternate Shipping Address (if different from usual address)

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Date Needed*

Time Needed*

: HH

MM

Is your Billing information different than your Contact information?*

Yes
No

Contact*

First Last

Phone*

Email*

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Billing and Invoice Preferences

Billing Preference*

Credit Card ♦
Company Check ♦♦

Invoice Receipt Preference*

Email
Mail

♦ We will call you for the credit card number. ♦♦ Three references will be requested to complete a client credit check.

Next Steps...

After your application has been reviewed, we will contact you to collect credit card details or company references, as well as authorization to complete a credit check.

Please call our office at 724-853-4047 for any questions regarding the application process.