[
Internetwines.com
] [
Faxable Order Forms
] [
Single Recipient
] [
Multiple Recipents
] [
Corporate Orders
]
CONTACT INFORMATION
Name
Phone
Email
Fax
Directions:
1. PRINT OUT THIS PAGE & FILL OUT (Yellow Sections are Optional)
2. FAX ORDER TO:
618-394-9383
SHIP TO:
BILL TO:
Name
Name
Address
Address
Address
Address
City, ST. Zip
City, ST. Zip
Phone
Phone
Payment type
Credit Card Number
Exp
.
MC / VISA / DISCOVER
Ship Method
Ship Date
Overnight / 2nd Day / 3 Day / Ground / Saturday
Qty.
Code
Item Description
Unit Price
Total
Gift Message/Special Instruction
Subtotal
Tax
Freight
Total
