CCK Automations, Inc.
500 Capitol Way
Jacksonville, Illinois, 62650 
Tel: 217-243-6040
Toll Free: 866-733-3227
Fax: 217-245-4105
e-mail: info@cckautomations.com
web: www.cckautomations.com

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CCK Automations Order Form
Customer Name___________________________________________________Date:________
Mailing Address_______________________________________________________________
e-mail Address________________________________________________________________
Item Description Item Price Qty.Ord Amt.Due
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_______________________________________ _____________ _____________ _____________
_______________________________________ _____________ _____________ _____________
_______________________________________ _____________ _____________ _____________
_______________________________________ _____________ _____________ _____________
_______________________________________ _____________ _____________ _____________
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Sub-Total _____________
IL Sales Tax 6.25% of sub-total _____________
Postage 7% of sub-total ($8.00 minimum) _____________
Total Amount Enclosed _____________
Substitutions/Special Instructions/Comments:
_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________
Credit Card #_____________________________________
(Master Card & Visa Only)		 Exp Date:
_____________		 Name on Card:
____________________

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© 2004 CCK Automations, Inc.