ORDER FORM 2-2-2012 by xiagong0815

VIEWS: 2 PAGES: 2

									www.SunsetSurvival.com
Phone: 714-369-8096 (local); 866-637-3440 (toll-free)
Email: support@sunsetsurvival.com
FAX: 714-625-8582


We accept Visa, Mastercard, AMEX, Discover - credit or debit cards.

                                                   Order Form

Billing Name & Address as it appears on your credit card bill

____________________________________________________________________________________
Name
_______________________________________ ___________________________ ______ _________
Address                                   City                     State   Zip

__________________________________________ ___________                __________________________
 Credit Card No.                           Exp. date                  CVV2 code -last 3 digits on back
                                                                      Visa/MC Disc 4 digits front Amex

_________________________ _____________                  ________________________________________
Phone Number (required)    Fax (optional)                Email (strongly recommended)



Shipping Name & Address if different from above: (If same, please check here ____)

Name: ___________________________________________________________________________

___________________________________ ____________________________ ____ _____________
Address                                   City                        State    Zip


CUSTOMER NOTES:_________________________________________________________________

____________________________________________________________________________________


Coupon or Promo code (if applicable)        _______________


Items ordered:

____________________          ________________________________________       _________ ________
Item Number                            Product Name                          Price (ea.) Quantity

____________________          ________________________________________       _________ ________
Item Number                            Product Name                          Price (ea.) Quantity

____________________          ________________________________________       _________ ________
Item Number                            Product Name                          Price (ea.) Quantity
                                  Order Form - Page 2

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity

____________________   ________________________________________   _________ ________
Item Number                     Product Name                      Price (ea.) Quantity



                             THANK YOU FOR YOUR ORDER!

								
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