PRODUCT ORDER FORM
     
Customer Name:
Phone:

Fax: Email:
Shipping Address:
Date:


Item Number
Item Name
Quantity
Unit Price
Total


















Credit Card Information (VISA / MC / AMEX / Discover, only)

Name on CC :

CC Number :

Expiration Date :

CC Security Number:
SubTotal:
Shipping & Handling:
Total:

AMOUNT OF ORDER
SHIPPING PRICE
Additional shipping charges will be added for heavy /bulk items.
$0.01 to $49.99
$9.50
  
$50.00 to $97.99
$14.50
  
$98.00 and up
Free
  

Address: 2575 Brookline Circle Atlanta, GA 30319
email: support@survivalbracelet.com - Toll Free: 1-888-330-9593 - Fax: 1-404-982-6344