Credit Card Order Form via Fax

Racing Pigeon Magnetite
Credit Card Payment by Fax
Authorization Form
Fax#:1-305-723-2783

Please Print Legibly

Name (as it appears on the credit card)
Address Line 1
Address Line 2 (optional)
City State/Prov./Prefecture Postal Code
Country (if not USA)
E-mail Address (needed for order confirmation) Home Phone
(        )		 Office Phone
(        )
Credit Card Number with Security Code Card (Visa, MC, Discover, Amex, Diners, Carte Blanche, JCB) Expiration Date
Name of Recipient (if different, optional)
Shipping Address (if different, optional)
Shipping Address Line 2 (if different, optional)
City State/Prov./Prefecture Postal Code
Country (if not USA)

I have read and agree to the following terms:

  1. I understand that Nature'sAlternatives.com uses the online retailer PaySystems.com, Inc. and that my order will be processed by PaySystems.com, Inc. resulting in a reference to myPaySystems.com, Inc. on my credit card statement.
  2. International Orders will be charged the cost of shipping in addition to the product cost.

X_____________________________________________________ Date_____________________________
Member's Signature (must match signature on file with your financial institution)

Please fill in the items you wish to order. Please be sure to include an e-mail address above so that you will receive your order confirmation.

Item Description Quantity Unit Price Subtotal
         
         
         
         
         
 
Coupon #: _____________________
 -$  

Comments:

 

TOTAL: