Credit Card Order Form via Fax

The Colloidal Silver Shoppe
Credit Card Payment by Fax Authorization Form
Fax#:1-305-723-2783

Please Print Legibly (Billing address must be exactly as it appears on your credit card statement. Shipping address can be different than billing address.)

Name (as it appears on the credit card)
Billing Address Line 1
Billing Address Line 2 (optional)
City State/Prov./Prefecture Postal Code
Country
E-mail Address (needed for order confirmation) Home Phone
(        )		 Office Phone
(        )
Credit Card Number Card (Visa, MC, Discover, Amex, Diners, JCB) Expiration Date
Name of Recipient (if different, optional)
Shipping Address (if different, optional)
Shipping Address Line 2 (if different, optional)
City State/Prov./Prefecture Postal Code
Country

I have read and agree to the following terms:

  1. I understand that Colloidal Silver Shoppe will use the online retailer PaySystems.com, Inc. and that my order will be processed by PaySystems.com, Inc. and that the charge for this purchase will reflect the name PaySystems.com, Inc. on my credit card statement.
  2. International Orders will be charged the cost of shipping in addition to the product cost.

X_____________________________________________________ Date_____________________________
Member's Signature (must match signature on file with your financial institution)

Please fill in the items you wish to order. Please be sure to include an e-mail address above so that you will receive your order confirmation.

Item Description Quantity Unit Price Subtotal
         
         
         
         
 
Coupon #: _____________________
 -$  

Comments:

 

TOTAL: