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Right Click HERE to Download a copy of this form in Microsoft® Word

 

FAX ORDER

TO

WWW.VIDNET.ORG

 

FAX TO

703-444-0473

SHIPPING INFORMATION:

SHIP TO:

YOUR NAME

 

ADDRESS LINE 1

 

ADDRESS LINE  2

 

CITY

 

STATE

 

ZIP CODE

 

 

 

EMAIL ADDRESS

 

TELEPHONE  NUMBERS

DAYTIME:

EVENING:

 

 

PRODUCT INFORMATION:

 

QUANTITY

NAME OF PRODUCT

PRICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBTOTAL PRODUCTS:

$

 

VIRGINIA RESIDENTS ADD 4.5% SALES TAX:

$

 

ADD SHIPPING:

$

IF DESIRED ADD  EXPRESS SHIPPING HERE:

 

 

 

TOTAL AMOUNT:

 

ADD SUBTOTAL PRODUCTS, SALES TAX, AND SHIPPING  TOTAL AMOUNT:

$

 

**US DOLLARS ONLY**

 

 

Your CREDIT CARD INFORMATION:

YOUR NAME (SAME AS ON CARD)

 

CARD BILLINGADDRESS LINE 1

 

ADDRESS LINE  2

 

CITY

 

STATE

 

ZIP CODE

 

 

 

WE ACCEPT VISA, MASTERCARD, AMERICAN EXPRESS, DINERS CLUB, and Discover

CREDIT CARD TYPE (VISA, MASTERCARD, ETC):

 

CREDIT CARD NUMBER:

 

EXPIRATION DATE ON CARD:

MONTH:

YEAR:

 

 

 

 

 

AUTHORIZATION:

 

I AUTHORIZE THE TOTAL AMOUNT TO BE CHARGED BY WWW.VIDNET.ORG TO MY CREDIT CARD FOR THE PURCHASE OF THE PRODUCTS LISTED ABOVE

SIGN HERE

Your Signature:

 

 

FAX TO 703-444-0473

WWW.VIDNET.ORG

21724 Pinewood Court

Sterling, VA  20164

Product Sales and Support Hotline:  703-409-3559

Copyright 1999 Financial Services, Inc.