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Order Form:

This form may be used for convenient on-line ordering if you already have an account with DRC Instruments. If you submit an order and you do not have an account with us, we will contact you to make payment arrangements.

To open an account with us, please click here to obtain a copy of our commercial credit application. Please print, complete, and fax this form to us to start an account.

Below are some common order and reorder items. If you wish to order anything that does not appear below, please describe it in detail in the space provided at the end of the form, or call DRC at (403) 280-8870 or send us a note by clicking here. Please fill in every field on the form below and submit it.

Company Name:

Your Name:

Purchase Order Number:

Important
Contact phone number including area code:

Ship to address:

Shipping instructions:
Please include any account numbers or other instructions needed. By default, all orders will be shipped Purolator ground collect. (For US customers, the default shipper is Airborne Express.)

Order
Please fill in quantities below.

Fleet Manager 100 Accessories:
FM100-SRM-2 Stop Recorder Module @ US$48/CDN$65.00 ea.

Please phone for quantity pricing.


Genuine VDO Kienzle charts:
(prices in Canadian dollars)
boxes 125-24CDN @ $13.00/box
boxes 125-24 mini @ $13.00/box
boxes 125x7x24 @ $20.00/box
boxes 125-2500-24CDN @ $19.00/box
boxes 125-3300-24CDN @ $19.50/box
boxes 80-2500-24 @ $20.50/box
boxes 125-3300-7x24 @ $22.50/box
boxes 80-3300-12 @ $22.00/box
boxes 125-4000-24 @ $23.50/box
boxes 80-8x24 @ $24.00/box
boxes 125-8x24 mini (1312) @ $20.00/box

Please phone for case-lot pricing.


Bulbs:
(prices in Canadian dollars)
KN 53-71-05-002 12-volt metal base tachograph bulbs @ $1.65 ea.
HW-004-067 12-volt black plastic base tachograph bulbs @ $1.50 ea.
HW-004-068 24-volt grey plastic base tachograph bulbs @ $1.85 ea.

Other:
Items not listed above (please give quantity and description).


Please tell us how you first found our site:


If you used a search engine, what did you search for?


How many vehicles are in your fleet?

Are there any other comments that you have? Please type them below:

Please read and acknowledge:
By clicking on the Submit button below, I acknowledge indebtedness for the goods ordered on this form. I certify that I am an agent of the purchasing company named on this form, and that I am authorized to make this purchase. Payment terms are 2% 15, net 30, 2.5% late charge after 60 days. I understand that DRC Instruments reserves the right to verify this purchase order before accepting it, but that it is not obligated to do so.



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