Fax Order Form

WWW.DIRECTLVS.COM - FAX ORDER FORM (800-471-3566)
Bill To Address:
Company Name
First Name		Last Name
Street Address
City		State		Zip	-
Country
Daytime Phone		Fax
Email

Ship To Address: (Check if this is the same as the bill to address)
Company Name
First Name		Last Name
Street Address
City		State		Zip	-
Country
Daytime Phone		Fax
Email

QTY	ITEM	DESCRIPTION	PRICE	SUBTOTAL















Subtotal
Tax %
Shipping & Handling (x 2.5%)
Total

Payment Methods
VISA	MASTERCARD	DISCOVER	AMERICAN EXPRESS

CUSTOMER ACCOUNT#	If you have Net30 payment terms check here
CARD NUMBER
EXPIRATION DATE (mm/yy)
3 DIGIT SECURITY CODE (excludes American Express
NAME ON CARD
BILLING ADDRESS (If different than standard billing address)
CITY, STATE, ZIP	-

PRINT AND FAX THIS FORM TO 800-471-3566

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