Order for Bimrose Lubricants
Please complete this form and fax to (07) 4921 3131		 Bimrose Lubricants P/L 
ABN 94 052 946 200
486 Quay Street
Rockhampton Qld 4700
P.O. Box 5537
Rockhampton Mail Centre
Qld., 4702
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Shipping details:
Your Company Name
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Your ABN Number
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Delivery Address
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 Postal Address
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Date
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Description of products required:
Quantity
Size
Description
Price
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 Total Price (Inc GST) 
 $_______
Please note: All freight is the responsibility of the customer.  Please nominate your carrier and account number when placing order.
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If making payment by credit card you must fill out all details in the following portion completely.
Credit card type: Visa | Bankcard | Mastercard  (Circle applicable)
Card Number: |_|_|_|_|  |_|_|_|_|  |_|_|_|_|  |_|_|_|_|     Expiry date: |_|_| / |_|_|

Name appearing on card: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|

Authorized signature: ____________________________
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