CREDIT CARD ORDER FORM
BILLING
ADDRESS
Name____________________________________________
Address_________________________________________
City ______________________________________________
State____________________________________________
Zip _______________________________________________
Country_________________________________________
Phone____________________________________________
E-Mail address____________________________________________
CREDIT CARD #____________________________________
TYPE CIRCLE ONE M/C
Visa Discover AmExpress
CVC Code 3 or 4 Digits on back of credit card______________________
Expire Date_______________________________________
Items you
wish to order.
Product 1__________________________________________
Product 2__________________________________________
Product 3__________________________________________
Product 4__________________________________________
Product 5__________________________________________
Sign your name or type it for e-mail _________________________________________
Shipping address same as billing :
YES______ NO______
If No fill out shipping
address information below
SHIPPING ADDRESS
Same as Billing Address:
Yes_________No______________
Name_____________________________
Business Name____________________________
Address________________________________________
City____________________________________________
State___________________________________________
Zip code________________________________________
Phone___________________________________________
FAX TO
US AT 240-332-6641
E-MAIL TO:
Origsquig@aol.com or Parts@Dumbassbiker.com