| BILLING INFORMATION: |
| NAME: ______________________________________
COMPANY: _______________________________ |
| ADDRESS: ___________________________________________________________________________ |
|
CITY:___________________________________________ STATE:______________
ZIP:______________ |
| PHONE (H):
____________________________
PHONE (C):_____________________________________ |
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E-MAIL ADDRESS*: _________________________________________FAX: _______________________ |
|
* Note: email address
needed to send order confirmation, receipt, and tracking information. |
| |
| CREDIT CARD INFORMATION: |
| Method of Payment: ___MasterCard
___VISA ___DISCOVER ___AMEX |
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16 digits |
16 digits |
16
digits |
15 digits |
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| NAME AS IT APPEARS ON THE CARD:
___________________________________________________ |
| EXPIRATION DATE: __________________
CVV Code: __________ |
| SIGNATURE:
__________________________________________________________________________ |
| |
| CHECK INFORMATION: |
| BANK NAME:
______________________________________________ TYPE OF ACCOUNT: |
[ ] SAVINGS
[ ] CHECKING |
| ROUTING NUMBER:
____________________________________________________________________ |
| ACCOUNT NUMBER:
___________________________________________________________________ |
| |
| SHIPPING INFORMATION: |
|
___SAME AS BILLING INFORMATION |
| RECIPIENT NAME: ___________________________________
PHONE: ___________________________ |
| STREET ADDRESS*: ___________________________________________________________________ |
|
CITY:___________________________________________ STATE:______________
ZIP:______________ |
|
* Note: We cannot ship to
a P.O. Box, we must receive a physical address to be able to ship an
order. |
