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Fax back to: 1 - 250 – 883 - 5439 Fill in ALL
areas below for manual processing. Please PRINT
all information clearly. Merchant
# ___________5845________________
US$ ONLY Merchant
Name __________Concept
Designz____________________ Product
Description ___________________________________________________________ Total price
$Subtotal w/Shipping = $__________x
4% Credit Card Fee = $____________ Cardholder
Name ____________________________________________ Billing
Address
___________________________________________________________ (where monthly credit card statements are sent, not
the shipping or company address) City ____________________________________________ Province/State
____________________________________________ Postal
Code/Zip ____________________________________________
Country ____________________________________________ Phone # ____________________________________________ (a telephone number is absolutely necessary) Credit Card
# ____________________________________________ Credit Card
Type ____________________________________________ Credit Card
Expiry Date ____________________________________________ Cardholder`s
Signature ____________________________________________ Email Address
____________________________________________
- Invoice is sent to Email Shipping info OR
write SAME if shipping to above address Address ____________________________________________ City
____________________________________________ Province/State ____________________________________________ Postal Code/Zip ____________________________________________
Phone # ____________________________________________ (a telephone number is absolutely necessary) |