Company/Purchasing Party Name

I acknowledge and affirm I am an authorized signature for abovenamed Company/Purchasing Party transactions. I authorize
to accept the following terms for Omega Distribution, for Cash on Delivery for Invoices submitted for payment:

Cashier’s Check
Money Order
I understand and acknowledge I will personally guarantee any orders refused or refuted by UPS for lack of funds, false payment or due payment and any handling/freight costs associated with any orders refused or refuted.

Name

Title

Street Address

City, State, Zip

Signature

Date

Driver’s License #

Expiration

Email Address

A copy of the Signature Party’s current, valid ID or Driver’s License must be included.