Get Free USA Shipping Over $99.00. Flat-rate Shipping Fee $6.95 otherwise.
Credit Card Payment by Fax
Authorization Form
Fax: +1-623-321-9977
Please Print Legibly (Address must be billing address for your credit card. If shipping address is different, you can also supply that information.)
Name (as it appears on the credit card) | ||
Address Line 1 | ||
Address Line 2 (optional) | ||
City | State/Prov./Prefecture | Postal Code |
Country (if not USA) | ||
E-mail Address (needed for order confirmation) | Home Phone ( ) | Office Phone ( ) |
Credit Card Number with Security Code | Card (Visa, MC, Discover, Amex, JCB) | Expiration Date |
Name of Recipient (if different, optional) | ||
Shipping Address (if different, optional) | ||
Shipping Address Line 2 (if different, optional) | ||
City | State/Prov./Prefecture | Postal Code |
Country (if not USA) |
I have read and agree to the following terms:
X_____________________________________________________ Date_____________________________
Member's Signature (must match signature on file with your financial institution)
Please fill in the items you wish to order. Please be sure to include an e-mail address above so that you will receive your order confirmation.
Item | Description | Quantity | Unit Price | Subtotal |
Coupon #: _____________________ | -$ | |||
Comments: | TOTAL: |