HDTV Supply - 2102 East Hillcrest Drive,
Thousand Oaks, CA 91362 USA - TEL: 805-277-1870
Print this form and use it for reference when placing your order by mail or FAX it to us at 805-277-9138.
| (A)
Ship To: (name and address) Fed Ex and UPS can not ship to Post Office Boxes or FPO/APO addresses |
(B) Bill To:
(please fill in bill to information if this differs from your shipping address) |
| Name: _____________________________ |
Name: ________________________________ |
| Address: ___________________________ |
Address: _______________________________ |
| Address: ___________________________ |
Address: _______________________________ |
| City: ____________ State: __________ Zip: _______ Country: ______ |
City: ___________ State: _________ Zip: ________ Country: ________ |
| Telephone: ______________________ |
Daytime Telephone: ______________ |
| Email: ____________________ |
Email: ____________________ |
| Above information must match your issuing banks records when using a credit card. |
(C) List of Items:
| Item #: | Item Name: | Quantity: | Price per Item: | Total: | |
| Subtotal $ |
(D) Totals & Shipping:
|
|
|
| Merchandise Total: $ | |
| Shipping (choose one) | |
| First Class Mail: __________ | |
| USPS Priority Mail: _________ | |
| UPS Ground Delivery: __________ | |
| UPS #-Day Select Delivery: _________ | |
| TOTAL: $ |
(E)
Method
of Payment:
___ Money Order (payable to "HDTV Supply)
___ American Express _____ MasterCard ____ Visa ____Discover
Credit Card # _____________________ &
Exp.
Date: ________ Security Code: _______
800 # on back of credit card__________________________
I agree to pay the above total amount according to card issuer agreement X_________________________ Date_______
