L & M Distribution Inc.
103 Jordan St. San Rafael CA 94901
Voice: 415-459-5565 | Toll-free: 800-772-4078 | Fax: 415-459-5569

L&M Distribution Order Form

Please feel free to call, or fax to place us an order. If you would prefer to place your order online, please enter your company name, telephone number, and credit card information, along with item numbers and quantities of the products desired. We will contact you via fax or email to confirm your order.

Your Name:
Company Name:
Street Address:
City:
State:
Zip Code:
Telephone:
Fax Number:
E-Mail Address
Comments

Please select the quantity desired, product item numbers as well as a product description and price.

Quantity Product Item # Description Price

* California Residents add 7.25% Tax

Credit Card Information (OPTIONAL - can also be sent by fax to 415-459-5569)

Visa Mastercard

Credit Card Number: Expiration Date:

Name Appearing On Credit Card:

Verify verification image, type it in the box

 

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