Heroines Fax/Mail Order Form

Fax to:

xxx.xxx.xxxx

Mail to:

Heroines Orders
xxx Street st
City, ST, XXXXX

Please include a separate order form for each Ship-To Address.
We only ship to the lower 48 United States via UPS Ground.
Fax or mail this form along with your check or money order or credit card information. DO NOT SEND CASH.
You will receive a confirmation e-mail when your order is received and processed.
Orders ship within 3 business days.

Heroines by Jila Nikpay
Hardcopy Edition
$xx.xx plus $x.xx shipping/handling
$x.xx total per set

Number of Sets:

Order Total :

Billing Information

Shipping Information
(if different from Billing Information)

Name: Name:

Address: Address:

City, State, Zip:

City, State, Zip:

Email:

Phone:

Payment Method

Money Order
Credit Card Information

Card number
Card Expiration Date

Signature (required for Fax Orders):

_____________________________________

Personal Check

Mastercard

Visa

Notes or Special Instructions:

Heroines Fax/Mail Order Form

Fill out the fields below. When finished, click the 'Print this Page' button at the bottom of this page.

xxx.xxx.xxxx

Heroines Orders
xxx Street st
City, ST, XXXXX

When finished, click the 'Print this Page' button to print this form.

Thank You For Your Order!

Billing Information		Shipping Information (if different from Billing Information)
Name:		Name:
Address:		Address:
City, State, Zip:		City, State, Zip:
Email:
Phone:

Payment Method
	Money Order	Credit Card Information Card number Card Expiration Date Signature (required for Fax Orders): _____________________________________
	Personal Check
	Mastercard
	Visa

Notes or Special Instructions:

Heroines Fax/Mail Order Form

Fill out the fields below. When finished, click the 'Print this Page' button at the bottom of this page.

xxx.xxx.xxxx

Heroines Orders xxx Street st City, ST, XXXXX

When finished, click the 'Print this Page' button to print this form.

Thank You For Your Order!

Heroines Orders
xxx Street st
City, ST, XXXXX