Hillary Machinery Inc 1825 Summit #207 Plano, Texas 75074 (800)683-1516 FAX (972)578-1519 On-Line Parts Order/Inquiry Form New Customer? Complete Our Credit Application to Apply for Terms Account (Sorry, Texas Customers Only) Also Accepted!

Purchaser Name: Machine Brand:Choose OneCincinnati Machine (Milacron)Giddings & LewisWarner SwaseyMilltronicsKearney & TreckerJones and ShipmanRepublic LagunLandis GardnerCincinnati IncorporatedTimesaver's IncQuickmillOther(Required) If not listed, input here Control Brand:Choose OneGE FanucSiemensG & LFagorAnilamVickersYasnac/YaskawaOther(if known) If not listed, input here Control Part Only? Input Control Serial Number here then go to PART INFOMRATION. Machine Model: Machine Serial Number: PART INFORMATION: Qty Part Description Part#(if known) Part Price (if known) All Prices Are Quoted FOB: Factory of Origin Action: (Choose One) Place Order and Send My Confirmation. My Purchase Order is: (Required) Inquiry Only. Just send me price and availability at this time Choose Shipping Method: (Choose one) Ground 2nd Day Air Overnight Overnight AM Delivery How would you like the shipping charges billed? (Choose One) Add Shipping Charges To My Invoice, or Charge to My Shipper Account (Indicate Shipper and Account Number Below) Shipper Name Shipper Account# Any Additional Instructions(Please Explain Below)

Delivery Information: Name: (Required) Company: (Required) Address 1: (Required) Address 2: City: (Required) State: (Required) Zip Code: (Required) Country: Voice Phone: (Required) Fax: Email: (Required)

Billing Information: (Choose one) Charge to Hillary Machinery Inc Net Terms Account (New Customers Must Complete Credit App) Charge to Credit Card Credit Card: Choose OneVISAMASTERCARD Card Number: Exp: (MM/YY) Cardholder Name:

Terms: Parts, Payment Net 10 Days Agree? Yes No