FAX/MAIL-IN ORDER FORM
Print this order form and
FAX to 518-674-0200 or Mail to
address on right.
Back
First Name: _______________________ Address: _______________________
Last Name: _______________________ City: _______________________
Phone: _______________________ State: _______________________
Fax: _______________________ Zip: _______________________
Email: _______________________
Qty Model Description Price Amount
___ __________________ ________________________ ____________ ___________
___ __________________ ________________________ ____________ ___________
___ __________________ ________________________ ____________ ___________
___ __________________ ________________________ ____________ ___________
___ __________________ ________________________ ____________ ___________
___ __________________ ________________________ ____________ ___________
___ __________________ ________________________ ____________ ___________
Confirm Order Via: Fax Email
Sub total:
 ___________
Payment Information:
 MC Visa Check
Sales:
 ___________
Credit Card Number:
 ____________________________
Shipping:
 ___________
Expiration:
_____________CVC#_____________
Sales Tax:
 ___________
(NY residents add 8% sales tax)
Total:
 ___________
Color Choices
First Braid color: _________________________
Second Braid Color: _________________________
Tie Off Color: _________________________
Charge Card Billing address if Different from Shipping Address
First Name: _______________________ Address: _______________________
Last Name: _______________________ City: _______________________
Phone: _______________________ State: _______________________
Fax: _______________________ Zip: _______________________
Email: _______________________
Purchaser Signature:________________________Date:____________

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