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200 Fire/Police Rapid Entry System � . <br /> AUTHORIZATION/ORDER FORM <br /> Effective 1/1/2000 <br /> ORDERED BY: INSTALLATION ADDRESSES <br /> (Required by Fire Department) <br /> Company/Person: A)1),eA I Date: List street addresses and cities where items <br /> �1 will be Installed.Attach separate sheet for <br /> !, >) <br /> Street: ln9 ,��),92i)&V ffL/fi �Ci additional installation addresses. <br /> City/State: I (jl A zip: D 3 1. Bldg.Name n <br /> Contart Person.x%jj OE5 L t i ><�Pi Phone:(425)743 -/335 Street 619 D g �r0 AG�L A AIJG <br /> RC.# (Gov.agencies only): CiIy diff, lyf} 9Y' o3 <br /> (Order.undo,$700 neu m pmpeYm•nf.J <br /> SHIP TO:(Street Address ONLY - No P.O.Box.) 2. Bldg Name <br /> Company/Person:) A N 1)E-5 4l"_-I—)el _ Street <br /> Street: /on a! r'a A d LJ AV AJ0_14 City <br /> City/State: t:—:: 41 c°X C +-t- l A :Zip: 9 R a(7 3 <br /> Contact Person:lz3/10 b r/,l f eI Pho4(//OS)1E1 J- 3-15 <br /> fflo Fe <br /> • , • • . ' <br /> WITHOUT SIGNATURE 3 <br /> O Ne to: <br /> ✓✓ <br /> Pj <br /> FVI-Rl-fT FIRS: MPT X93 <br /> 2099 OAKES AVF Ca <br /> SI •dM1—e to <br /> EVERETT WA 98201- <br /> AUTHORIZED <br /> 8201-A THORIZE FIRE AVENCYSION RF St �p <br /> PS-10-022 !� <br /> VE <br /> System Code <br /> USE iii PRODUCT PRICE LISTONBACK rGE <br /> Oty. Part # Item Description Color Weight Price Ea. Total IMPORTANT <br /> 2V _ 'DID ❑ Check here if <br /> products ordered on <br /> this form must be <br /> ass <br /> DUAL KEYED <br /> MAKE CHECKS PAYABLE TO: KNOX COMPANY SUBTOTAL S_777-°� Add $7.00 to EACH <br /> r Shipping & Haidling Add Sales Tax If Applicable item ordered <br /> lot: CA', GA,IL,NJ,OH $ <br /> 1 Ib. to 25 lbs. $10.00 Shipping&Handling $ i0• a a <br /> I 1 26 Its.to 50 lbs. $20.00 TOTAL: $ COMPANY <br /> I <br /> W , 51 lbs. to 75 lbs. $30.00 800-552.5669. 949.252-8181 <br /> 75 lbs.+call Knaxfor quO. 'CA Tex:7.25% • CA,Grange County Tac 7.75% Fax: 949.252.0482 <br /> www.knoxbox.com <br /> 0•aW IM 000M101 ONO,co Np'Nv'999 <br />