Order Form

Purchase Order to Rogers & Lough Marine Engineers Date: ____/____/____
Company: _______________________________________________________
Address: ________________________________________________________
Suburb: _________________________ State: ________ Postcode: _________
Phone: (_____)____________________ Fax:(_____)_____________________
Email: __________________________________________________________
Ship via: Air Bag / Mail / Courier / Freight Company / Collect Personally

Qty:	Description:	Price:










	TOTAL	$

I hereby quote sales tax registration number:

Please tick one:
	I will sell the goods to a particular person who has quoted a sales tax registration number or an exemption declaration in respect of that sale.
		____________________

Accordingly, I quote this declaration; or I quote this declaration as authorised representative for the business or organisation mentioned below.

Quoter's Signature: _______________________________________________
Quoter's Full Name: ______________________________________________
Name of business or organisation (if applicable): ________________________
Address: _______________________________________________________
Suburb: _________________________ State: ________ Postcode: ________
Contact Telephone Number: (_____)____________________

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Rogers & Lough Marine Engineers
82 Taylor Street, Bulimba,
Brisbane, Qld, 4171, Australia
Ph.: +61 7 3399 3433
Fax: +61 7 3399 3211
Email Rogers and Lough

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