Fax Order Form

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CODE

DESCRIPTION

PRICE EA.

Downloadable fax order forms are available in Adobe PDF and Microsoft Word formats.
PDF format	Word format

FAX ORDER FORM

eburch.biz

421 East College Street Florence, AL 35631
Fax 1-256-764-3183

Name___________________________________________________________________________________

Address____________________________City_______________State_________________Zip___________

PLEASE: We really need your phone number to contact you just in case there's a problem with your order.

Daytime Phone (_______)______________________ Evening Phone (_______)______________________

E Mail Address __________________________________________________________________________

Please tell us how you found us._____________________________________________________________

May we backorder merchandise?Yes No

Total of All Merchandise Ordered
Add $15.00 when ordering rods
SHIPPING & HANDLING (Required) Standard
AIR SHIPMENTS 1-Day 2nd day
SUBTOTAL 8% (.08) Calculate tax on subtotal if order is shipping within Alabama
TOTAL

METHOD OF PAYMENT

MASTERCARD®(16 Numbers) VISA®(13-16 Numbers)

AMERICAN EXPRESS®(15 Numbers)

Please include the numbers on the metallic portion of the card ___ ___ / ___ ___ Expiration Date (Required)


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CARDHOLDER'S SIGNATURE__________________________________________