Fill and Sign the Order Acknowledgement Form

Acknowledgement and Acceptance of Order Date: ________________ To: ____________________ (Name of Customer) The undersigned ______________________ (Name of Recipient) , of _____________________________________________________________________ (street address, city, state, zip code) , hereby acknowledges the receipt and delivery of the (describe goods) _________________________________________________ described in Exhibit A attached hereto, made a part hereof, and initialed by Recipient. We confirm our acceptance of the said Order subject only to the following exceptions: (describe) __________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________ . Regarding the exceptions, the undersigned shall assume you agree to same unless written objection is received within ten days of the date of this notice. Witness my signature this_______ day of_______________, 20____. __________________________ (Printed Name of Recipient) __________________________ (Signature of Recipient) (Acknowledgment form may vary by state) State of _____________________ County of ___________________ Personally appeared before me, the undersigned authority in and for the said County and State, on this ___________________ (date) , within my jurisdic tion, the within-named _______________________ (Name of Recipient ) , who acknowledged that he executed the above and foregoing instrument. ________________________________ NOTARY PUBLIC My Commission Expires: ____________________