|
WEB
ORDER FORM
Print
and Mail or Fax to (631) 584-7670 |
437D
North Country Road, St. James, NY 11780 - (631) 584-7674 |
| Date |
Email |
Phone/Fax
(Area Code First) |
| Name: |
| Address: |
Apt.: |
| City: |
State: |
Zip/Postal
Code: |
| Province |
Country |
For
Credit Cards, please fill out as shown below:
Never
Email Credit Card Information
|
| Please
PRINT Exact name as it appears on card: |
| Card
Number: |
Verif.
# on Card |
| Exp.
Date: |
Signature: |
Card
Type - CIRCLE ONE |
Visa |
Amex |
Discover |
Master
Card |
Other: |
Check
or Money Order - Please wait 3 days for checks to clear. |
Specify
Billing Address BELOW if Different from Mailing
Address:
|
Item
No. |
Description |
Color |
Size |
Qty |
Price
Each |
Subtotal
(Qty
X Price) |
| |
|
|
|
|
|
|
| |
|
|
|
|
|
|
| |
|
|
|
|
|
|
| |
|
|
|
|
|
|
| |
|
|
|
|
|
|
| |
|
|
|
|
|
|
| Special
Instructions |
Subtotal |
|
Tax
(NYS
residents add
8.625%) |
|
Shipping
CLICK
HERE FOR SHIPPING RATES |
|
| TOTAL |
|
Invoice
number and total cost confirmation will be sent via email
to the address provided. |
| |
| |
| |
| |
| |
