To Place Your Order by Fax please print out this form and Fax it To:
(573) 624-3146
Missouri Residents please add 5.225% for Sales Tax to Total.
Quantity |
Description | Price Each |
|---|---|---|
| $ | ||
| $ | ||
| $ | ||
| $ | ||
| $ | ||
| $ | ||
| $ | ||
| $ | ||
| $ | ||
Subtotal |
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Missouri Sales Tax (For Missouri Residents Only) 5.225% |
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| Shipping | For Orders over $100.00 free shipping | |
| For Orders between $65-$99.99 add $5.00 for shipping | ||
| For Orders less than $65.00 please add $8.50 for Shipping | ||
Total |
| Name | |
|---|---|
| Billing Address: | |
City |
_________________________State:________________________Zip:____________ |
| Phone Number: | _____________________________Email:______________________________________ |
| Please Provide Us with either your phone number or email so if there are any delays or questions we may contact you. | |
| Credit Card |
(Visa___) (MasterCard___) Card Number____________________________________ Expiration Date (00/00)__________________________________________________ Verification Code (Only for Visa Cards)___________________ This is found on the back side of your Visa Card . Where you sign your name there is a long list of digits in the upper right hand side of the signature. We need the last 3 digits of the code. Signature:____________________________________________________________ |
| Ship To Address if different from the address above. | Name:_______________________________________________________________
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