Product Order Form

Product Order Form

Hidden Fields

To order this product, please fill out the form below. A customer service representative will contact you shortly to confirm your order with price and delivery. NOTE: BRECOflex CO., L.L.C only sells to customers in North, South and Central America. If you are outside of this territory please contact your regional distributor.

Order Information

Are you an existing customer?

YesNo

Is this a new order or a reorder?

New OrderReorder

What is your Customer Number?

If you have a quote # please enter it here.

What is the PO# or Invoice # from your previous order of this product?

Product Category

Item Number or Part Name (Enter, or Copy and Paste from Product Detail Page)

For timing belts, specify belt width (mm)

For timing belts, specify belt length (mm)

For timing belts, specify construction

Order Quanitiy

Please provide any addition details about this part.

Upload any related documentation such as PO, drawings, etc.

Upload any related documentation such as PO, drawings, etc.

DO YOU NEED TO ORDER A 2nd ITEM?

YesNo

2nd Item

If you have a quote # please enter it here.

What is the PO# or Invoice # from your previous order of this product?

Product Category

Item Number or Part Name (Enter, or Copy and Paste from Product Detail Page)

For timing belts, specify belt width (mm)

For timing belts, specify belt length (mm)

Order Quanitiy

Please provide any addition details about this part.

Upload any related documentation such as PO, drawings, etc.

Upload any related documentation such as PO, drawings, etc.

DO YOU NEED TO ORDER A 3rd ITEM?

YesNo

3rd Item

If you have a quote # please enter it here.

What is the PO# or Invoice # from your previous order of this product?

Product Category

Item Number or Part Name (Enter, or Copy and Paste from Product Detail Page)

For timing belts, specify belt width (mm)

For timing belts, specify belt length (mm)

Order Quanitiy

Please provide any addition details about this part.

Upload any related documentation such as PO, drawings, etc.

Upload any related documentation such as PO, drawings, etc.

DO YOU NEED TO ORDER a 4th ITEM?

YesNo

4th Item

If you have a quote # please enter it here.

What is the PO# or Invoice # from your previous order of this product?

Product Category

Item Number or Part Name (Enter, or Copy and Paste from Product Detail Page)

For timing belts, specify belt width (mm)

For timing belts, specify belt length (mm)

Order Quanitiy

Please provide any addition details about this part.

Upload any related documentation such as PO, drawings, etc.

Upload any related documentation such as PO, drawings, etc.

DO YOU NEED TO ORDER a 5th ITEM?

YesNo

5th Item

If you have a quote # please enter it here.

What is the PO# or Invoice # from your previous order of this product?

Product Category

Item Number or Part Name (Enter, or Copy and Paste from Product Detail Page)

For timing belts, specify belt width (mm)

For timing belts, specify belt length (mm)

Order Quanitiy

Please provide any addition details about this part.

Upload any related documentation such as PO, drawings, etc.

Upload any related documentation such as PO, drawings, etc.

Contact Information

First Name

Last Name

Title

Company

Address 1

Address 2

City

US State

State/Province (if outside the US)

Zip/Postal Code

Country

Email

Phone

Phone Ext (if any)

Fax

Is the billing information different from the above?

YesNo

Billing Information

First Name

Last Name

Title

Address 1

Address 2

City

US State

State/Province (if outside the US)

Zip/Postal Code

Country

Email

Phone

Phone Ext. (if any)

Fax

Is the shipping information different from Contact Info?

YesNo

Shipping Information (If different from above)

Company Name

Address 1

Address 2

City

US State

State/Province (if outside the US)

Zip/Postal Code

Country

Special Instructions, if any.

Our preferred shipping method is UPS, but can ship FedEX express saver. Please provide collect account number, otherwise, order will ship via PPD and freight amount will be added to your invoice

Enter shipping method and account number, if applicable.

Opt-In and Privacy

Opt-in/Opt-Out

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Privacy Policy Acknowledgement

By submitting this form, you acknowledge that you have read BRECOflex CO., L.L.C.'s Privacy Policy, agree to its terms, and consent to allow BRECOflex CO., L.L.C. to use your information consistent with the Privacy Policy. Read our Privacy Policy here.

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