FAX ORDER FORM - FAX TO : 919-528-1739 - 24 HOUR FAX LINE
To order by fax print this form, fill out and fax to us.

Item Sku Number
Description
Quantity
Price Each
Total
         
         
         
         
         
         
      Sub Total  
      N.C. Residents
Add 6% Tax
 
      Shipping Add 15%  
      Total  

SHIPPING
INFORMATION
PAYMENT/BILLING INFORMATION
PLEASE FILL IN ALL AREAS
First Name_______________________________ Method of payment: Check_____ Money Order_____
Last Name_______________________________ Credit card_____________
(Visa, Mastercard, American Express, Discover)
Shipping Address _________________________ Credit Card #_____________________________
City ______________________State__________ Expiration date___/____/____ (mm/dd/yyyy)
Email Address: ________________________ CCV Number _______ (last 3 digits, back of card, signature line)
Zip Code______________ Billing Address _______________________________
Home Phone___________________ City, State, Zip _______________________________
Work Phone____________________ Cardholderís name____________________________
Fax Number____________________ Signature____________________________________

E-Mail us at sales@ssautochrome.com

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