Fax-Back Customer Order Form
Direct Advantage
A division of ICM Corp., Inc.
520 W. Oklahoma Ave. - Milwaukee WI 53207
Phone: 1-800-669-7766 - 1-414-290-1000 - Fax: (Toll Free) 888-369-0788

Three Ways To order
1: Credit Card: We gladly accept Visa, Mastercard, American Express and all Novus Cards. 2: Prepayment - 100% deposit is sufficient to speed orders to first time customers. 3: Open Account - Credit is extended to all government offices and to private businesses with approved credit. Payment is expected in 30 days.
Have you ordered from us before Yes No Customer Number:
Billing Address Shipping Address
Company Name
Company Name
"Bill To" Address:
"Ship To" Address:
State, Zip:
State, Zip:
Purchase Order Number:
Dept. Code on back of catalog:
Special Delivery Instructions:
Page # Quantity Model No. Description/Dimensions Price Ea. DA% DA Price Total
All Prices F.O.B. Origin (call for freight quote)  
Bill Company net 30 days (per approval)  
Check or Money Order Enclosed  
Visa Master
Novus IMPAC¹
expiration date:      /      /       
WI residents add sales tax
or supply resellers certificate
Merchandise Total  
Freight Charges  
Grand Total  
Print name on card
Signature of person ordering
Authorized Signature
Date and Phone
Prices and manufacturer's product specification subject to change without notice. Products ordered at different times may not match. To save freight costs, most items are shipped requiring some assembly. Prices subject to change without notice.
¹I.M.P.A.C. is a registered servicemark owned by Rocky Mountain BankCard System and used by Direct Advantage Corp., Inc. under authorization of Rocky Mountain BankCard System.