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

Shipping Information:

First Name

Last Name

Company Name

Shipping Address

(billing address is below)

City

State / Province

Zip / Postal Code

Country

Quote Number:

Phone

Fax

Shipping Method

Ship Account #

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

1st Part Number

2nd Part Number

3rd Part Number

4th Part Number

5th Part Number

6th Part Number

7th Part Number

8th Part Number

Subtotal: $

Total Amount: $

Notes or Special Instructions

I agree to the Terms & Conditions (Warranty)

Billing Information:

First Name

Last Name

Company Name

Billing Address Line

Example: 1234 Test Lane

Zip / Postal Code

City

State / Province

Country

Billing Phone

Email Address

Confirm Email Address

Credit Card Number

Expiration Month

Expiration Year

Secret Code (CVV)