Om-Fax-Order-Form by liuqingyan



                                    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 Our address for orders by mail is Om Tibetan
Jewelry, 11316 Hattery Lane, Austin, TX 78717.

      Item #                  Item Name                  Unit Price           Quantity   Subtotal

 Sales Tax (Texas Residents Only-8.25% of the above amount)
 Shipping (Please refer to the shipping cost table listed in the instructions)

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


I authorize Om Tibetan Jewelry to charge the above amount to this credit card.

Signature: _____________________________ Date: ________________________

                       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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