Indiana Billing, Shipment & Pickup Request Form

1010 N. Sycamore St.

North Manchester, IN 46962

Main: (800)334-3628

Fax: (260)982-1130

intextbook@hfgroup.com
Billing, Shipment & Pickup Request Form

This form must be completed and on file before your work will be processed.
PURCHASE ORDER NUMBER (REQUIRED)*
Date*

MonthDayYear
SCHOOL NAME*
SHIP TO ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
CONTACT NAME*
CONTACT EMAIL*
example@example.com
CONTACT NUMBER*
EXTENSION (optional)
BILL TO SCHOOL NAME*
BILL TO ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
BILL TO NAME*
BILL TO EMAIL*
example@example.com
BILL TO CONTACT NUMBER*
EXTENSION (optional)
ALTERNATE CONTACT NAME*
Person who can be reached during the summer
ALTERNATE CONTACT EMAIL*
example@example.com
ALTERNATE CONTACT NUMBER
LAST DAY OF SCHOOL*

MonthDayYear
Date
FIRST DAY OF SCHOOL*

MonthDayYear
Date
Required Authorization
AUTHORIZED PERSON NAME*
Person who can be reached during the summer
AUTHORIZED PERSON TITLE*
DATE*

MonthDayYear
TRUCK SERVICE PICKUP REQUEST: Fill out only if you qualify for pickup service.

A minimum of 100 books is required for pickup
NUMBER OF TEXTBOOKS (PIECES)*
NUMBER OF LIBRARY BOOKS (PIECES)*
LOCATION OF BOOKS (door #, room name, area, etc.)*
CENTRALIZED PICKUP/DELIVERY LOCATION*

YESNO
CENTRALIZED PICKUP/DELIVERY ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
For Office Use Only
ACCOUNT NUMBER
GP
HBI
SPSH
DIST
SCAN
For Distribution Use Only
PICKUP DATE
DELIVERY DATE
# OF BOXES PICKED UP
ROUTE NUMBER
# OF BOXES DELIVERED
ROUTE NUMBER
PICKUP SIGNATURE
DELIVERY SIGNATURE
Should be Empty: