Billing
Form:
Please fax this form to:
(323) 466-9217
First Name:
Last Name:
Email Address:
Phone:
Address:
City, Zip:
Color
GREEN-BURGUNDY
GREEN-GREEN
BLUE
BLACK
--------------------
How Many
1
2
3
4
5
6
7
8
9
10
------
Color
GREEN-BURGUNDY
GREEN-GREEN
BLUE
BLACK
--------------------
How Many
1
2
3
4
5
6
7
8
9
10
------
Color
GREEN-BURGUNDY
GREEN-GREEN
BLUE
BLACK
--------------------
How Many
1
2
3
4
5
6
7
8
9
10
------
Credit Card Type
AMERICAN EXPRESS
VISA
MASTER CARD
DISCOVERY
Credit Card Number
Expiration Date
Signature
For your protection please fax this form, or you can submit
via E-mail!