Print out this form, fill it in, and FAX it to us at 1.601.825.8375 ( Secured Facsimile )

BILL TO INFORMATION:

For fraud prevention, and MAINLY YOUR PROTECTION , the Credit Card Companies require the address where your credit card statements are sent. If the Name, Address, Phone Number, and Credit Card Number do not match, the Credit Card will  NOT be approved  This second level of security is important to safeguard you number.

Circle which Credit Card is being used:

American Express

Carte Blanche   

Dinners Club

Discover  

MasterCard

Visa

PLEASE PRINT

Credit Card Number:

   Expiration Date: Month:   Year:  

Name on Credit Card:

  

Address:

 

Address 2:   Email Address:  
Day Phone Number: :   Evening Phone Number:  
City:   State:  

Zip:

  
Country:   Signature:  

DELIVER TO INFORMATION::

Name:   Business Name:  

Address:

 

Address 2 :

 

City:   State:  

Zip:

  
Country:   Phone Number:  

Delivery Date:

  

Web Item Number:

 

Price of Web Item:

  

Web Item Description to Order:

 

Card Message:  
 
Special Instructions:  
 

*Note* a $ 9.95 Handling Fee will be added to each order. Sunday delivery is not available in most areas. We will email you an acknowledgement receipt of your order to insure you it transmitted correctly