Purchase Order Form | Hayes Manufacturing, Inc.

This form is for credit card orders in the US and Canada only. For international orders, please call (231) 879-3372 to arrange for payment.

The payment button will not activate unless all required fields have been filled, the order amount is greater than $0.00, and you have agreed to the terms and conditions.

PO Number(Required)

Shipping Information

(billing information is below)

First Name(Required)

Last Name(Required)

Company Name(Required)

Shipping Address(Required)

City(Required)

State / Province(Required)

Zip / Postal Code(Required)

Country(Required)

Quote Number

Phone(Required)

Fax

Shipping Method(Required)

Ship Account #

Residential Address?(Required)

Parts

Enter a part number to reveal quantity and price fields for up to 8 parts:

1st Part Number

1st Part Quantity(Required)

1st Part Quoted Price(Required)

2nd Part Number

2nd Part Quantity(Required)

2nd Part Quoted Price(Required)

3rd Part Number

3rd Part Quantity(Required)

3rd Part Quoted Price(Required)

4th Part Number

4th Part Quantity(Required)

4th Part Quoted Price(Required)

5th Part Number

5th Part Quantity(Required)

5th Part Quoted Price(Required)

6th Part Number

6th Part Quantity(Required)

6th Part Quoted Price(Required)

7th Part Number

7th Part Quantity(Required)

7th Part Quoted Price(Required)

8th Part Number

8th Part Quantity(Required)

8th Part Quoted Price(Required)

Total Amount

This field is hidden when viewing the form

Hidden Total

Notes or Special Instructions

Tax Exempt Certificate(Required)

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Billing Information

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Email(Required)

Enter Email Confirm Email

Billing Phone(Required)

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Total cost cannot be $0.00.

Name

This field is for validation purposes and should be left unchanged.