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ABCDEFGHIJKLMNOPQRST
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TimestampSample Question 1
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123GDS DBA ARISING INC
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15942 lOS SERRANOS COUNTRYCLUB
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SUITE D241ONLINE FAX/MAIL IN ORDER FORM
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CHINO HILLS, CA 91710For Internal Use Only
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FAX ORDER TO (909) 464-1236 or email to arising1@gmail.com
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BILLING ADDRESS
SHIPPING ADDRESS
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Name:_________________________________________Name:____________________________________
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Address:_________________________________________Address:____________________________________
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Address 2:_________________________________________Address 2:____________________________________
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City:_________________________________________City:____________________________________
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State:_________________________________________State:____________________________________
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Zip Code:_________________________________________Zip Code:____________________________________
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Email:_________________________________________Email:____________________________________
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Telephone #:(____)____________________________________Telephone #:(____)_______________________________
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Telephone number MANDATORY: only use in case we need more information.
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(__) Check here if you have an account with us. Acct #_______________
(__) Check here if Ship To Address is the same as the Bill To Address
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ORDERING INFORMATION
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ITEM #COLORMODELITEM DESCRIPTION
NoteQTYPRICETOTAL
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EACHPRICE
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123White1200OpenerTrigger1$ 49.99$49.99
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PAYMENT
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Preferred Shipping MethodSUBTOTAL:$________
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(__) USPS(__) UPS Residents add 0.00% Sales Tax:$________
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Standard Ground OnlyShipping & Handling:$________
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Priority & Overnight not available
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( ) Optional Insurance USPS:$____3.00
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Preferred Payment Method(Fragile items and items over $25 automatically insured)
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(__) Cashiers Check or Postal Money OrderCoupons and Promotional Codes (subtract):-$_______
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Up to 10 business days delay due to bank processing
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(__) Personal Check or Other Money OrderTOTAL:$________
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Up to 15 business days delay due to bank processing
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(__) PayPal
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(__) Credit Card - VISA __________________________ MC __________________________
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DISCOVER __________________________ AMEX __________________________
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(__) Western Union Money Transfer:MTCN:____________________
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(__) Walmart Money CenterMTCN:____________________
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Make Checks and Money Orders Payable To:
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Send Order Form along with Payment To: 15942 los Serranos County Club Suite D241 Chino Hills, CA 91709
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All orders will ship when payment has cleared. Confirmation email with tracking information will be sent when order has shipped.
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If no payment is received within 5 business days of receipt of this order form, your order will be cancelled..
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If you authorize payment for credit card to be charge your signature is required and is keyed in a mail order.
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Signature: _______________________________________Date: _____/_____/_______
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