EQUIPMENT & SERVICES SALES RECORD
lI)r3m
EQUIPMENT ANCtERVICES SALE RECORD .
NCR Corporation NCR HE~RENCE NUMBER
CUSTOMER NAME CUSTOMER NUMBER Df.\T1~, eREPARED
c't.,. .4- f ", ,i." -~r ,- ". r7.' ,
'.,1\, w ;).:': '~, ,~- ',",' ,-
STREET ADDRESS EQUIPMENT TO BE
t! !, "'~.f , 0 0
1! I., ':,."')'"'1,,'-' '. NEW USED
" ;.~ \.,p', , '.
CITY COUNTY STATE I ~I~; ~~D~ MAINTEN. COVERAGE
(',1 ~'(':t, ' tcr' Pin'''ll }li)rL,,' D o DO NOT
BILL BILL
FOR USE AT CUSTOMER NUMBER PRII\1E ~~I'lT"
""j
) .\'"
STREET ADDRESS ADD'L COVERAGE
Yi :', h . (~~~. :l.~ ,:~ -~- "', ~- ":" - t~ %
CITY COUNTY S}1 ~)~~'l I ZIP COD)' PAF,l,C,VI~E.~!.
., ,"C' Pit; ," 11 " > ': " 1 t ',""'... ,
',,' L ,,;
SHIPPING INSTRUCTIONS: o GOV'T DX RATING CUSTOMER AGREES TO BUY AND NCR, ON ACCEPTANCE,
CFAPPLIED FROM INV. o CUSTOMER ADDRESS AGREES TO SELL THE FOLLOWING, NCR MAY INSERT THE
" SERIAL NUMBERS OF THE EQUIPMENT AND THE INITIAL
0 NCR LOC. CODE ,~.... PAYMENT DATE WHEN ASCERTAINED.
DIST. ADM. CODE f "
B/S/A IDENTIFICATION UNITS SERIAL NUMBERS UNIT PRICE EX~r~~ED TOTALS AMOUNT
r, ':::,t, ~)" :r1 1
) (':" ~. ,,'
~'l ;:; _r" r; :,) (1 ()' \ ]~ L :'~\. '7 7' r,;: . ':'. .,,7'; LIST PRICE + .. , ..
\ J, ..}L, ) I.J~1~' j? _ r~..', ~ " 1 " '" , ~ , ' - ,
,_ r".
2 +
ADJUSTMENTS - ", '~ "
~.. , ' ..
" -, U'l :: - ,......f., :".'"3 ,--"1-: L; "~C " 3 " "
' , NET TOTAL , ;
': C, -rn (~)) ,~.,)~~lt 1 J_ ; " htr. = . 1
+ .,) r J,~l~
4
STATE TAX +
5
COUNTY TAX + -.
6
LOCAL TAX + ..
7
RECORDING & + ..
, FILING FEE
8
DISTRIBUTION + .-
CHARGE
TRADE IN CREDITS + AMOUNT 9
CL/IDENT. SERIAL NO. AVAILABLE LOCALDELY .-...
TIME PAYMENT BALANCE ITEM +
-- CHARGE
(15) TO BE PAID IN 10 ,',
MONTHLY INSTALLMENTS OF TOTAL = ,
-
AND A FINAL 11
INSTALLMENT OF -- C.W.O. -
DISCOUNT
THE FIRST INSTALLMENT TO 12
-- CASH ON ,.
OTHER ) ,c"..} r: ,~ BE PAID ON DELIVERY -
:i,"1:t , C~l"" .. .'~ ..t 't.'~, \'~ '1,
., / /. ,.I - AND THE OTHERS SERIALLY 13
AMOUNT '"
RECEIVED - ON 19 - ON THE SAME DAY OF EACH =
FINANCED
- 14
AS THE CASH WITH ORDER PAYMENT PROVIDED HEREIN SUCCEEDING MONTH.
FINANCE -
(ITEM 11) CHARGE +
SIGNATURE OF 15
NCR REPRE, TIME PAY'T <---
SENTATIVE BALANCE -
NOTICE TO RETAIL BUYERS 1. DO NOT SIGN TH.S CONTRACT BEFORE YOU READ IT OR IF IT CONTAINS ANY
BLANK SPACES. 2. YOU ARE ENTITLED TO AN EXACT COPY OF THIS CONTRACT COMPLETELY FILLED IN AT THE
TIME YOU SIGN IT. 3. UNDER THE STATE LAW REGULATING INSTALLMENT SALES, YOU HAVE CERTAIN RIGHTS,
AMONG OTHERS (1 ) TO PAY OFF THE FULL AMOUNT DUE IN ADVANCE AND OBTAIN A PARTIAL REBATE OF
THE FINANCE (CREDIT SERVICE) CHARGE, (2) TO REDEEM THE PROPERTY IF REPOSSESSED FOR A DEFAULT
WITHIN THE TIME PROVIDED BY LAW, AND (3) TO REQUIRE, UNDER CERTAIN CONDITIONS A RESALE OF THE
PROPERTY IF REPOSSESSED. 4. KEEP THE COpy OF THIS CONTRACT TO PROTECT YOUR LEGAL RIGHTS.
FURNISHING OF THE EqUI~ME,~~, PROGRAMS AND/OR SERVICES IS DONE ONL Y IN ACCORDANCE WITH AND PURSUANT TO OUR
.... 1,,_,
AGREEMENT DATED
;:,itYJ( ClparWa::"l'
"-'11::' l3. ~'hy,j, City !<'.anag" r
CUSTOMER NAME (TYPE OR PRINT)
BY ClJSr0r,lGl ::Opy
SIGNATURE AND TITLE
F,8233 NCR 0376 0- / c.f7?' -
d
3
m[3rn Corporation
OlloTATION FOR EQUIPMENT AND SERI.ICES
CUSTOME R:
DATE PREPARED
DESCRIPTION
UNITS
UNIT PRICE
EXTENDED PRICE
SPECIAL INSTRUCTIONS:
THE FOllOWING STATEMENT(S) MUST APPEAR ON YOUR
PURCHASE ORDER.
FURNISHING OF THE EQUIPMENT, PROGRAMS AND/OR SER-
VICES IS DONE ON l Y IN ACCORDANCE WITH AND PURSUANT
TO OUR AGREEMENT DATED
ADJUSTMENTS
DESCRIPTION
AMOUNT
SUBMIT PURCHASE ORDER TO
N C R CORPORATION
SUBMITTED BY:
N C R REPRESENTATIVE
F-8232 NCR,0376
THE ABOVE PRICES ARE SUBJECT TO CHANGE WITHOUT NOTICE.