Fax Order Form

Please Print this form and fax it to (US) 718-347-2587

 

DATE__ __ ____

NAME________________________________

ADDRESS_________________________________

____________________________________________________

TEL #________________

EMAIL______________________

CARD HOLDER NAME____________________

ADDRESS_________________________________

_________________________________________

COUNTRY__________________

CREDIT CARD TYPE______________

CREDIT CARD #____ ____ ____ ____

EXPIRATION DATE___________

SIGNATURE___________________________

MODEL #_________________QTY___________

MODEL #_________________QTY___________

MODEL #_________________QTY___________

MODEL #_________________QTY___________

COMMENTS______________________________