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Le.com DATE TO CONSIGNEE: STREET STREET ORIGIN: CITY STATE ZIP CODE DESTINATION: CITY EXIT: STATE ZIP CODE STATE ZIP CODE PHONE PHONE P.O. No. Freight Payment Terms Freight Charges are Prepaid Unless Marked Collect Check Box if charges are Collect COD $ C.O.D. Fee Terms Prepaid Collect FULL VALUE INSURANCE REQUESTED NO. SHIPPING UNITS KIND OF PACKAGING HM THIRD PARTY BILL-TO: STREET Is a company check acceptable for payment? Yes - Check Here CITY No ATTN: PHONE INVOIC.

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