|
Please
print this form, provide all information requested, and return
by fax or regular mail.
Fax to: 423-775-0611. Mail to: Interactive Products Corporation,
148 Bluff Road, Dayton, TN 37321.
Please Note: We
DO NOT accept personal checks.
We DO accept money orders.
Customer
Billing Information
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|
Name:
|
_________________________________________________________ |
|
Company
Name:
|
_________________________________________________________ |
|
Bill
to Address:
*Address must
be as
it appears on your
credit card statement
|
________________________________________________________ |
| _________________________________________________________ |
| _________________________________________________________ |
|
City:
|
_________________________________________________________ |
|
State:
|
________________________ |
Postal
Code:
|
___________________ |
|
Country:
|
________________________ |
|
Phone:
|
________________________ |
E-mail:
|
___________________ |
|
|
|
Customer
Shipping Information
|
|
|
|
___
Check here if the Ship To Address is the same as the Bill To Address
|
|
|
|
|
Name:
|
_________________________________________________________ |
|
Company
Name:
|
_________________________________________________________ |
|
Ship
to Address:
|
_________________________________________________________
|
| |
_________________________________________________________ |
| |
_________________________________________________________ |
|
City:
|
_________________________________________________________ |
|
State:
|
________________________ |
Postal
Code:
|
___________________ |
|
Country:
|
________________________ |
|
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| |
|
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Credit
Card Information
|
|
We
accept Visa, Master Card, Discover and American Express.
|
| |
|
|
Card
Number:
|
__________________________
|
|
Expiration
Date:
|
_______________
|
| |
|
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Mobile
Office Product Information
|
| Quantity: |
Size: |
Description:
|
Item
Number: |
| _______ |
____ |
_________________________________ |
_________________ |
| _______ |
____ |
_________________________________ |
_________________ |
| _______ |
____ |
_________________________________ |
_________________ |
| _______ |
____ |
_________________________________ |
_________________ |
| _______ |
____ |
_________________________________ |
_________________ |
| _______ |
____ |
_________________________________ |
_________________ |
