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TM-10109-16 Rev 1 City of La Porte - Lomax & Tom Brown Park <br />QUOTE <br />#76051 <br />11/03/2016 <br />Please complete and return with your required form of payment: <br />Acceptance of quotation: <br />Accepted By (printed): _________________________________ P.O. No: _____________________________ <br />Signature: ___________________________________________ Date: ________________________________ <br />Title: _______________________________________________ Phone: ______________________________ <br />Facsimilie: __________________________________________ Purchase Amount: $52,949.52 <br />Order Information: <br />Bill To: _____________________________________________ Ship To: _________________________________________ <br />Company: ___________________________________________ Company: ________________________________________ <br />Attn: ________________________________________________ Attn: ____________________________________________ <br />Address: _____________________________________________ Address: _________________________________________ <br />City, State, Zip: _______________________________________ City, State, Zip: ___________________________________ <br />Contact: ______________________________________________ Contact: _________________________________________ <br />Email Address: _______________________________________ Email Address:_____________________________________ <br />Tel: _________________________________________________ Tel: ____________________________________________ <br />Fax: _________________________________________________ Fax: ___________________________________________ <br />For non-taxable purchases: Please also provide a copy of your Sales Tax Exemption Certificate or Resale Certificate. <br />Page 3 of 3 <br /> <br />