SECURE ORDER FORM

SECURE ORDER FORM

IMPORTANT ! AFTER YOU SUBMIT THIS ORDER A NEW SCREEN

WILL PRESENT YOU WITH A VISUAL CONFIRMATION ALONG WITH YOUR ORDER NUMBER.


Special Note To FireFox & Apple Computer Users. Please do not press the ENTER key during this session. Use the tab key or the mouse to advance to the next field.	CONTACT INFORMATION

E-Mail
Phone Number
First Name
Last Name
Company Name


SHIPPING DETAIL

Is Delivery To A Residential Address ?
Purchase Order / Reference #
Attention
Street
Suite/Unit
City
State / Province
NON USA/CANADA
Zip Code Postal Code
Country
Ship Via
Carrier Account # ( Required for next day delivery.)
Alternative Shipping Method

TERMS
	Client agrees that all prepaid freight charges will be added to the invoice and that the vendor will not be held responsible for delays, lost items, damages or non performance by carrier. Client accepts any and all additional freight charges for this order to be added to the credit card should vendor receive additional billing from carrier for either corrected weight, dimension changes or any other charges that may be levied in addition to the original freight charges. Orders for custom made items are not cancelable nor returnable for any reason whatsoever. All items ordered via email without a written purchase order are non returnable. TYPE USING ALL UPPER CASE CHARACTERS INTO THE BOX BELOW I AGREE

CREDIT CARD

Credit Card Type
Card Holder's Name :
Bill To Street
Bill To City
Bill To State / Province
Bill To Zip/Post Code
Country
Credit Card # ( No Spaces )

Card Expiry Date ( MM / YY)
The 3 OR 4 Digit Security Code Of Card :

REFERED BY
How Did You Find Us ?

Promotion Code :

ITEM 1 DETAIL

Quantity :
Item Description :
Product ID ( If Known ) :
UNIT PRICE

ITEM 2 DETAIL

Quantity :
Item Description :
Product ID ( If Known ) :
Unit Price :

ITEM 3 DETAIL

Quantity :
Item Description :
Product ID ( If Known ) :
Unit Price :

ITEM 4 DETAIL

Quantity :
Item Description :
Product ID ( If Known ) :
Unit Price :

ITEM 5 DETAIL

Quantity :
Item Description :
Product ID ( If Known ) :
Unit Price :
Additional Items / Comments ?