SURPLUS ELECTRONICS MARKET PO Box 289 Dakota, IL 61018 Voice (815) 449-2624 Fax (fax is currently out of service)
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Online Order Form
Please see our ordering information page if you haven't already
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This is not a secure page If you're uncomfortable sending information via e-mail,
call Aaron at 815-449-2624
Note:Do not fill out this form until your have confirmed price, avaliability & shipping costs through e-mail or phone/fax
Product(s) Name or Description
Auction site and item Number (if applicable)
Price Shipping & handling
Sales Tax (6.75% Illinois Only) Total
Credit card type:
Credit card Account Number:Expiration (MM/YY)
Credit Card Billing Address:
Your Name (exactly as it appears on card)
Address
City
StateZipcode
Home Phone
Your E-mail address
Shipping Address: (only if different from billing address) (international orders please put shipping address in the special instructions box)
Name
Address
City
State Zipcode
Special Instructions

By clicking the submit button you agree that you have read and understand our Ordering Information and Policy pages and authorize us to bill the amount shown in the price shipping & tax boxes to your credit card.


Please press the submit button only Once
If an e-mail window pops up when you press the "submit" button, then your browser is not compatible with this form and you can put all the information into an e-mail and send it to us. Else fax your order via the instructions at the top of the page.
If you don't receive an order confirmation e-mail within 24 hours let us know so we can re-process your order
Do not submit this from until you have confirmed price, avaliability & shipping costs

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