Parts and Accessories Order Form and Combined Quote Request Form

Benz Compressed Air Systems Inc sells parts and accessories within Southern California only. If you are located outside of Southern California, we cannot be of service. Thank you in advance for your understanding.

This online form has been designed to provide you with an alternative method of ordering and quoting your compressed air system parts and accessories needs.

We are always standing by ready to handle your phone requests toll free at 800-698-4247!

Please fill in all required areas of the form in order to facilitate prompt and courteous processing of this request. Your information will be transmitted to the Benz Parts Department immediately after you press the submit button, and you should receive a reply within 4 hours from the time the request is submitted. If your request is received after 1:00 p.m. PST, we will respond by the next business day.

Thank you for selecting Benz Compressed Air Systems Inc for your parts and accessories requirements. We hope our online forms will help save you time and give you the ability to place orders at your convenience. Please submit any suggestions regarding this form to partsbenzcas.com.

Note: Items marked with an asterisk * are required fields, thank you!

Order Information

I am submitting an order. I am submitting a quote request.

Customer Number	Order Date *	Date Required *	P.O. Number

Shipping Information

You must enter your area code and country code (if applicable) in the telephone number fields, e.g. 1-714-555-1212.

Contact Name *	Direct Tel/Ext *	Ship Via	Email *
		<Choose One> UPS Ground UPS 3 Day UPS 2 Day UPS Next Day UPS Collect UPS COD Bus UPS COD Res FedEx P1 FedEx Economy FedEx Collect Common Carrier Other (Indicate)

Shipping Method for UPS | FedEx Collect | Other

Optional: Use the area below to include account number for shipping products via UPS Collect or FedEx Collect and to indicate other shipping method.

Carrier	Ship Via Account Number	Ship Via Other
Choose UPS FedEx Other

Bill To and Ship To Information

Company Bill To *	Company Ship To *
Same as Ship To
Bill To Contact	Bill To Tel/Ext

Make | Model Number | Serial Number

Make 1	Model Number 1	Serial Number 1
Make 2	Model Number 2	Serial Number 2
Make 3	Model Number 3	Serial Number 3

Special Instructions and/or Comments

Quantity | Part Number | Description

#	Qty	Part Number	Description
01
02
03
04
05
06
07
08
09
10

All of us at Benz wish to thank you for your order and we look forward to being of service. It is suggested that you print a copy of the order confirmation page that is generated once you press the Submit button.

Last modified: 2008-09-17T15:08:20-0700