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www.omtibetanjewelry.com Fax / Email / Mail Order Form To place an order by fax, email, or mail, please print and fill out this form. This order can be faxed, emailed, or sent by regular mail. Our fax number is (512) 284-8312. Our email address for orders by email is email@example.com. Our address for orders by mail is Om Tibetan Jewelry, 11316 Hattery Lane, Austin, TX 78717. Item # Item Name Unit Price Quantity Subtotal Subtotal Sales Tax (Texas Residents Only-8.25% of the above amount) Shipping (Please refer to the shipping cost table listed in the instructions) Total Payment Information ❏ Check or Money Order (Payable to Om Tibetan Jewelry) Pay by Credit Card ❏ Visa ❏ MasterCard ❏ American Express ❏ Discover Card Number: __________________________________________________________ Expiration Date: Security Code: Billing Address Shipping Address (If different) Name Name Street Address Street Address City State Zip Country City State Zip Country Phone Email: I authorize Om Tibetan Jewelry to charge the above amount to this credit card. Signature: _____________________________ Date: ________________________ www.omtibetanjewelry.com Om Tibetan Jewelry Order Form Instructions (Please do not fax, email, or mail this to us. This is for your reference only.) 1. Shipping Cost Domestic Shipping (Within the US) Order Amount Shipping Rate Under $49.99 $5.65 $50 Up Free International Shipping Order Amount Shipping Rate Under $50 $12 $51-$99 $14 $100-$200 $18 $201-$300 $24 $301-$400 $28 $401 Up Free 2. Item Number The item number is the number above the item price. I.E. Tibetan-sterling-pendant-50 is the item # for the following item.
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