Leyman Lift Gates office hours are from 8:00 a.m. to 5:00 p.m. (Eastern Daylight Savings Time). Please note that you must have an existing account before utilizing this form. To place an order through our web site, please complete the following form. If a credit card is being used, we will contact you by phone to obtain all necessary information. If you submit your order after 5:00 p.m., your order will not be processed until the next business day. If you have any questions about your order, please contact our Customer Service Department at 1-866-539-6261

Billing Information:

Leyman Customer Account No.

Company (required)

Address (required)

City (required)

State (required)

—Please choose an option—ABAKALARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENHNJNLNMNSNTNYOHOKONORPAPEQCRISCSDSKTNTXUTVAVTWAWIWVWYYT

Postal / Zip (required)

Country

—Please choose an option—USACanada

Your Name (required)

Your Email (required)

Phone (required if using a credit card)

Purchase Order #

Will use a credit card. We will contact you to obtain the necessary information.

Ship To:

Shipping Address is the same as Billing Address

Company

Attention

Address

City

State

—Please choose an option—ABAKALARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENHNJNLNMNSNTNYOHOKONORPAPEQCRISCSDSKTNTXUTVAVTWAWIWVWYYT

Postal / Zip

Country

—Please choose an option—USACanada

Shipping Method:

—Please choose an option—UPS GroundUPS 2nd Day AirUPS Next Day AirUPS Next Day Air (early AM)UPS Next Day Air (Saturday Del.)Federal Express AIRParcel Post MailPriority MailExpress Mail1st Class Mail2nd Class Mail3rd Class MailOther - Specify below

Special Shipping Instructions

Lift Gate Information (parts will be used on this gate)

For us to keep track of any parts ordered for specific lift gates, it is important for you, as a customer, to fill in the model and/or serial# of the gate.  The information also gives us a better idea if the part number you have provided for us is the correct part to ship to you/your customer.

Model #

Serial #

Parts

1. Qty. Part Number Description:

2. Qty. Part Number Description:

3. Qty. Part Number Description:

4. Qty. Part Number Description:

5. Qty. Part Number Description:

6. Qty. Part Number Description:

7. Qty. Part Number Description:

8. Qty. Part Number Description:

9. Qty. Part Number Description:

10. Qty. Part Number Description:

Additional comments

Δ