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Fax Order Form |
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Customer Information |
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Customer Name |
___________________________________________ |
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Street Address |
___________________________________________ |
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City |
___________________________________________ |
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State / Zip |
___________________________________________ |
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E-mail Address
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___________________________________________
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Item
Information |
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Wig Name |
___________________________________________ |
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Wig Brand |
___________________________________________ |
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Wig Color |
___________________________________________ |
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Payment Information |
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Name on Credit Card |
___________________________________________ |
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Billing Street Address |
___________________________________________ |
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City |
___________________________________________ |
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State / Zip |
___________________________________________ |
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Credit Card Type |
Visa / MasterCard (Circle
One) |
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Card Number |
___________________________________________ |
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Expiration Date |
___________________________________________ |
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Signature |
___________________________________________ |
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By signing above, you are authorizing
Wigs.md parent company Joshua24.com to charge your credit card for the products
ordered plus shipping and handling charges. |
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