WJS Enterprises Online Supply Order Form

<body link="#0000FF" vlink="#0000FF" alink="#FF0000"> <table border="0" cellpadding="0" cellspacing="0" width="600" height="100%"> <tr> <td valign="top" width="100" bgcolor="#33CCFF" height="100%" align="center"> <table border="0" cellpadding="2" cellspacing="0" width="100" style="font-family: Arial; font-size: 8pt; text-transform: uppercase; font-weight: bold; color: #0000FF; text-align: Center" align="left"> <tr> <td width="100" height="200%" align="center"> <p align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><b><br> <a href="html/online_supplies.htm" target="_self"><span style="text-transform: uppercase">ORDER SUPPLIES ONLINE</span></a></b></font></p> </td> </tr> <tr> <td width="100" height="100%" align="center"> <p align="center"><span style="text-transform: uppercase"><a href="html/supply_info.htm" target="_self"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><b><br> SUPPLY INFORMATION REQUEST</b></font></a></span></td> </tr> <tr> <td width="100" height="100%" align="center"><span style="text-transform: uppercase"><a href="html/supply_faq.htm" target="_self"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><b><br> SUPPLY FAQ</b></font></a></span></td> </tr> </table> <p>  </td> <td valign="top" width="512" bgcolor="#FFFFFF" height="100%" align="center"> <script Language="JavaScript" Type="text/javascript"></script><form method="POST" name="FrontPage_Form1" onsubmit="return FrontPage_Form1_Validator(this)" action="_vti_bin/shtml.exe/SupplyOrderHome.htm" webbot-action="--WEBBOT-SELF--" language="JavaScript"> <input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"> <div align="center"> <center> <table border="0" cellpadding="2" width="100%"> <tr> <td width="100%" colspan="2"> <h1 align="center"><b><font face="Verdana, Arial, Helvetica, sans-serif" size="4" color="#0000FF"> <br> WJS Online Supplies Order Form</font></b></h1> <p align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Use this form to order your supplies from WJS Enterprises, Inc. online.<br> <br> Orders are delivered by our trucks within the Greater New Orleans and Baton Rouge Metro Areas. All others are shipped via UPS and usually arrive the next day. </font></p> <p align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">When all entries have been made depress the <b> "Submit Order Button"</b> below to enter your order.</font></p> </td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Company Name: </font></td> <td width="73%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Company" size="35"></font></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Delivery Address:</font></td> <td width="73%"><input type="text" name="delivery_address" size="35"></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Delivery City:</font></td> <td width="73%"><input type="text" name="delivery_city" size="30"></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Delivery State:</font></td> <td width="73%"><input type="text" name="delivery_state" size="20"></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Delivery Zip:</font></td> <td width="73%"><input type="text" name="delivery_zip" size="20"></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Contact:</font></td> <td width="73%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="contact" size="30"></font></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Position:</font></td> <td width="73%"><input type="text" name="contact_position" size="35"></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Email Address:</font></td> <td width="73%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="email" size="35"></font></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Phone Number:  </font></td> <td width="73%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="phone" size="20"></font></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> Fax Number:     </font></td> <td width="73%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="fax" size="20"></font></td> </tr> <tr> <td width="100%" colspan="2"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><br> Select a Method of Payment<br> Note that a confirmation of Charges will be sent prior to shipment<br> <br> <input type="radio" value="on_account" checked name="bill_method">Bill my Account (Enter Account Number below)<br> <input type="radio" name="bill_method" value="cod">COD<br> <input type="radio" name="bill_method" value="credit_card">Credit Card (Credit Card Information & Signature Form will be sent)</font> <p><font face="Verdana, Arial, Helvetica, sans-serif" size="2">How would you like your confirmation Sent?</font></p> <p><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="checkbox" name="confirm_by_email" value="ON">Email<br> <input type="checkbox" name="confirm_by_fax" value="ON">Fax<br> <input type="checkbox" name="confirm_by_phone" value="ON">Phone</font><br> </td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Account Number:</font></td> <td width="73%"><input type="text" name="account_number" size="20"></td> </tr> <tr> <td width="27%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">P.O. Number:<br> (If Required by<br> your company)</font></td> <td width="73%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="PO_Number" size="30"></font></td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="2" width="100%"> <tr> <td width="100%" align="center"><font face="Times New Roman, Times, Palatino, serif" size="3"><br> </font><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> WJS Equipment ID Number : <input type="text" name="wjs_id_number" size="20"></font></td> </tr> <tr> <td width="100%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b> AND / OR</b></font></td> </tr> <tr> <td width="100%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> Equipment Make : <input type="text" name="make" size="15" value="Canon"><br> and Model : <input type="text" name="model" size="20"></font></td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="2" width="100%"> <tr> <td width="5%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><br> </b></font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><br> Qty</b></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><br> Item Description</b></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 1</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_1" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_1" size="40" value="Toner by the case"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 2</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_2" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_2" size="40" value="Staples by the case"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">3</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_3" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_3" size="40" value="Letter Size Copy Paper by the case"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 4</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_4" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_4" size="40"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 5</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_5" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_5" size="40"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">6</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_6" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_6" size="40"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 7</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_7" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_7" size="40"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 8</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_8" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_8" size="40"></font></td> </tr> <tr> <td width="5%" align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 9</font></td> <td width="9%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Qty_9" size="10"></font></td> <td width="86%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><input type="text" name="Line_Item_9" size="40"></font></td> </tr> </table> </center> </div> <p align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2">Use the Box below to enter any additional comments, shipping<br> and or billing information.</font></p> <p align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><textarea rows="10" name="Comments" cols="50"></textarea><br> <br> <b> Enter your Order by depressing the "Submit Order" button. <br> The "Reset" button will clear all the forms fields<br> </b></font><br> <input type="submit" value="Submit Order" name="B1">      <input type="reset" value="Reset" name="B2"></p> </form> </td> </tr> </table> <p align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><span style="text-transform: uppercase">| <a href="index.html" target="_top">HOME</a>  |  <a href="html/AboutUS_Home.htm" target="_top">ABOUT US</a>  |  <a href="html/Product_home.htm" target="_top">PRODUCTS</a>  |  <a href="html/Supply_home.htm" target="_top">SUPPLIES</a>  |  <a href="html/Service_home.htm" target="_top">SERVICE</a>  |  <a href="html/Featured_home.htm" target="_top">FEATURED</a>  |  <a href="html/Employment_home.htm" target="_top">CAREERS</a>  |  <a href="html/News_home.htm" target="_top">NEWS</a> |</span><a href="mailto:webmaster@wjsenterprises.com"><br> </a><br> This Page Last Revised on : August 12, 2003 <br> Copyright © 2001 [WJS Enterprises, Inc.]. All rights reserved.<br> For Questions and Comments about this Web Site email <a href="mailto:webinfo@wjsenterprises.com" target="_blank">webinfo@wjsenterprises.com</a></font> </body>