ONLINE MARKET ORDER FORM - FAX to (207)596-7292
SHIPPING INFORMATION
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Date
to be shipped:
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______/_______ |
(Order
will be delivered the next day.) |
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Ship
to::
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_________________________________________________ |
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Company:
|
_________________________________________________ |
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Address:
|
_________________________________________________ |
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City:
|
____________________ State:_______ ZIP:___________ |
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Recipient
Phone:
|
_________________ |
OK
for FEDEX to leave order if no one is home? ____
(Jess' cannot be responsible for any orders left)
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|
CREDIT
CARD PAYMENT DETAILS
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Visa
Mastercard
Discover Exp. date __ __--__
__ |
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Credit
card number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__
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Name
as it appears on card:_____________________________________
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Cardholder's
Signature:_____________________________________
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Issuing
Bank:_____________________________________
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Billing
Address:
|
_________________________________________________ |
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City:
|
____________________ State:_______ ZIP:___________ |
|
Daytime
Phone:
|
_________________ |
