Sample Order Form
(Can be modified in any way)
.
Please print this form
and
Fax to:
000-000-0000
or mail to
YOUR COMPANY ADDRESS
I authorize (
YOUR COMPANY
NAME HERE)
to Charge my Credit Card,
for the amount indicated below.
AMOUNT:__________________________________________
NAME:_____________________________________________
ADDRESS:__________________________________________
PHONE NUMBER:____ ______________________________
E-MAIL ADDRESS:__________________________________
CITY:___________STATE:________ ZIP CODE___________
CREDIT CARD INFORMATION:
VISA(
.
) MASTERCARD(
.
) American Express(
.
) Discover(
.
)
CREDIT CARD NUMBER:____________________________
EXPIRATION DATE: MM___ YY___
.
SIGNATURE:________________________________________
All information is Private and Secure.
We will not give or sell this information to anybody.
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