Bill To:

Customer Name: _________________________________________________________
Contact Person Name:_____________________________________________________
Mailing Address: ________________________________________________________
City: _______________________________ State: _________________ Zip: ________
Phone #: _____________ Fax #: _______________ E-Mail: _______________________
Total Purchase Order Amount: __________ Tax I.D.:____________________________
Payment Terms: __________________ Payment Amount:_________________________
Credit Card #: _____________________ Credit Card Type: ________ Exp. Date:______
Name On Card: __________________________Card Signature: ___________________
Check Number: _____________________
Person Order Confirmed By (Print Name):_____________________________________
Signature Of Person Confirming Order: _______________________________________

Ship To:

Customer Name: _________________________________________________________
Shipping Address (Street & Number): ________________________________________
City: _______________________________ State: _________________ Zip: ________
Salesperson: ____________________________________________________________
Purchase Order Number: ___________________________________________________
Order Date: ___________ Arrival Date:___________

“Soda Pop Top” Counter/Shelf Box Display:

Counter/Shelf Display Box (24 pops) - Cost: $________ Quantity: _________
Master Case (144 pops) - Cost: $________ Quantity: _________
Per Unit Cost: $______
Per Unit Suggested Retail Price: $______
Purchase Amount: $__________

“Soda Pop Top”Beverage Cooler/Shelf Clip Strip Display:

12-Pop Clip Strip Display, 3-Pack (36 pops) - Cost: $ _________ Quantity: _________
Master Case (18, 12-pop clip strips, 216 pops) - Cost: $__________ Quantity: __________
Per Unit Cost: $______
Per Unit Suggested Retail Price: $______
Purchase Amount: $__________

* All individual lollipop displays contain a mix of six popular flavors. All prices subject to change.
* Make checks payable to: Eagle River USA, LLC. Please fax us this purchase form for credit card orders.