(You can print this page and complete it manually as well)

REQUIRED INFORMATION for placing FAX, MAIL or E-MAIL ORDERS

Personal Data:

·          Name

·          Street address

·          City

·          State or Country

·          Zip Code or Postal Code

·          Delivery Phone Number

·          Work Phone Number (if applicable)

·          Home FAX Number (if applicable)

·          Work FAX Number (if applicable)

·          E-Mail Address

Shipping Data:

·          Name

·          Street address
(Remember... There needs to be someone at this location to accept the delivery!)

·          City

·          State or Country

·          Zip Code or Postal Code

·          Delivery Phone Number

·          Work Phone Number (if applicable)

·          Home FAX Number (if applicable)

·          Work FAX Number (if applicable)

·        Delivery E-Mail Address

Product Information:

·         Manufacturer

·         Model number

·         Quantity of each item (that you wish to order)

Financial Information:

·         Total cost of product(s)

·         Total cost of Shipping, Handling and Insurance

·         TOTAL SENT

·         Check or Money Order number

Credit Card Information:

·          Credit Card Type (Visa, MasterCard, Discover or American Express)

·          Your Name (EXACTLY as it Appears on the Credit Card)

·          Credit Card Number

·          Credit Card Expiration Date   ___  ___  /  ___  ___

·          Credit Card Three (3) Digit Code (Visa, MC & Discover)  ___  ___  ___

(This is on the reverse side of your VISA, MASTERCARD or DISCOVER CARD follows the signature panel.)

·          Credit Card Four (4) Digit Code (American Express)  ___    ___  ___  ___

(For the AMERICAN EXPRESS CARD a 4 digit code is located on the front side of the card just above the last five (5) digits of the card number.)