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® K NOX•, Rapid Entry System Fire • EMS • Law Enforcement • Government Effective p Y Y F.po E r January 1, 2009 2009 AUTHOR ORDER FORM LIFE SAFETY , 09-131875 800 - 552 - 5669.623- 687 -2300 • Fax: 623 - 687 -2290 • WWW.KNOXBOX.COM Section 1 ORDERED BY COMPANY / NAME DATE ORDERED 1 1111111111111 11111111111 _11 11 +1+ STREET SUITE / BUILDING t HIHHHILIHlIHHLH I I t CITY STATE ZIP CODE 1111111 III I IIIII I — t CONTACT NAME P.O. NUMBER (GOV. AGENCIES ONLY) t IHIIHJIHIIIIIIIHIHHIIHH PHONE NUMBER E -MAIL ADDRESS r 111 —■1■- 1111111 111111111111111 111111 P i Section 2 ORDER WILL NOT BE PROCESSED IMPORTANT NOTE - Knox Master Keys are provided to authorized agencies Without Authorized Signature or other registered entities on an as- needed basis solely for use tath the Knox Rapid Fntry System. No other use of the Knox Master Keys or their associated cork-, is authorized or pennilted. Knox Master Keys and Key Codes assocrateri i:iith the Knox iiiilastei Keys and Keys °Jays remain the Ze h rhIIIS Fire Rescue exclusive property of the Knox Conipan; Key Codes a ssociated ',nth the p Y Knox Master Keys and Keyi.: y i, are maintained bvv the Knox Company in 6907 Dairy Rd Phoenix. Arizona. For (luestrol_ s regarding this policy. contact Knox at Zeph rhills FL 33542 800- 552 -5669. ■ / _ .ii Authorizing Agency Approval Signature Required ., „ , i � _ _,� 9 1; • j j rn . to Sub - master Items A one ' nc Ig re and Date Print Name Clearly 0 Check here to Sub - master PS- 1 - 0253 -U1 - US Sub - master fee $7.00 per keyed Item. System Code Authorized Agency Signature ........: Section 3 PRE- PAYMENT Section 4 ORDER PRODUCT HERE — USE ATTACHED PRICE LIST INFORMATION REQUIRED Quantity Part# Weight Ea. Price Ea. Extended Price 13 Check or Money: Order made payable 1 / 3 1 2-1 dI 1 1 1 $ 21 / Is . 1 012> $ B� c” 0 t2 KP10X "COMPANY Federal 1.0. 1954617858 k D VISA D M C E XP. DATE (MM /Y Y) I I IIII I , $ I I . I . $ III . i. 0 AMEX 0 DISC 1 T I I 1 1 1 1 1 1 $ I. I $ l.. CARD NUMBER Sub- master Fee I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (if required $7.00 ea.) $ s Shipping and • NAME ON CARD .— Handling $ I I I I I I I I I I I I I I I I I I I J 1 1 1 I I l I I 1 1 1 I I 1 C ardholder Signature Subtotal $ 1 1 1 ,.. Section 5 INSTALLATION ADDRESS - REQUIRED BY AUTHORIZED AGENCY Sales Tax $ 1 BUILDING NAME (WHERE ITEM WILL BE INSTALLED) - PLEASE TYPE ADDITIONAL INSTALLATION ADDRESSES ON ASEPARATE SHEET (REQUIRED BY FIRE DEPT.) FL TAX Require I I_ I 1_ I I I I I I I I I I 11 I I I I Pre- pay Total $ I 1 1 1 II STREET ADDRESS (NO P.O. BOXES) r' 1 1 1 1 1 [ I I I I I I 1 1 1 1 1 f i l l - Ground 7 Shipping 1 A0 Handling CITY STATE ZIP CODE 8113s. to 25 lbs. $22.00 Alaska, Hawaii, g I IIIII IIIII I I III 261bs. to 50 lbs. $37.00 Canada, li please call 51 Ibs to 75Ibs. $48.00 Knox ler quote. t Section 6 SHIP TO ADDRESS IS REQUIRED ■SAME AS INSTALL ADDRESS SHIP TO CONTACT NAME -"t.:;„, Gt l $or R hteFend t he*Box. , 1 1 1 1 1 1 1 I I 1 1 1 1 1 1 1 1 1 1 1 1 : r , r i a yAir 1]lnd Day A r COMPANY NAME COUNTY 0/N I I I I I I I I f 1 I l I I I L I I I I I R E C D , ; STREET ADDRESS (NO P.O. BOXES) S this form with payment t0: 1 1 1 1 1 1 I. 1 1 (l l l l l l l l I l l KNOX COMPANY CITY STATE ZIP CODE 1601 W. Deer Valley Road 1 1 I I I l 1 1 , 1 I I I 1 1 1 1 1 Phoenix, AZ 85027