U.S. Fax Order Form

Eyespyvideo.com United States Fax Order Form

Print and complete this form then fax to 800-568-6353 or 314-993-4803

Company Name

 

Contact Name

 

PO#

 

Phone

 

Fax

 

Email

 

Billing Address

 

 

 

 

 

Shipping Address

 

 

 

 

 

Top of Form

Credit Card Type: Visa MasterCard American Express

Credit Card Account Number: _________________________________________

Expiration Date: _____/____/____________   *Security / CVL Code: ____________

 

Top of Form

*Note: For Visa and MasterCard this code is the last three digits printed on the card's signature strip (back of card). For American Express (AMEX) accounts, this is a four-digit code found on the front of the card following the card number.

Bottom of Form

 

I, as purchaser, hereby agree that I have read and agree to the terms and conditions provided herein regarding the use of this web site and all products / equipment contained or listed on this site. I certify that I am 18 years of age or older and am capable of receiving item(s) ordered. I further understand that it is my responsibility to ascertain and obey any and all local, state, and federal laws regarding the use of these products in my own state, province, or country. Furthermore, I will not hold Eyespyvideo.com responsible or liable for any use or misuse of its products. I grant permission for the credit card account above to be charged for the full amount of products plus applicable shipping costs and taxes (MO residents only).

 

 

 

X____________________________________________________

Signature REQUIRED for all orders by fax

Item Number

Quantity

Price / Each

Extended Item Total

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Order Subtotal:

$

Flat Rate Shipping Amount (see table below):

$ OR:

Check FedEx Rush Service:

Priority AM Overnight

Standard PM Overnight

FedEx 2-Day Service

Missouri (MO) residents only, please add 7.575% state sales tax (multiply subtotal by 0.07575)

$

Total Amount of Requested Order:

$