Fax Order Form Bill to Address:__________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Ship to Address:__________________________________________________ (If different) _______________________________________________________________________ _______________________________________________________________________ Contact Phone # ________________________Email:_____________________________________________ Item # Description Price Quantity Total _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Subtotal of order:_______________ (We will phone you with estimated shipping charges, prior to delivery)Shipping:____________ Order Total:_______________ Payment Information Information below required to process Credit Card orders: Type of Credit Card: Visa___Mastercard___American Express___ Credit Card Card Number: __________________________________ Valid from: ____Expiration date:_______ Name as it appears on credit card: ______________________________________________ Card holders phone: (please be sure to include area code) _______________________ Card Holders signature: (Required)_______________________________________________