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INSTRUCTIONS:  Please print this page and fax it to (321) 777-9058
or call us at (321) 777-5936 with your order.

Ordered By:  (Please print CLEARLY!)

Name:  

_________________________________________________

Address:  

______________________________________________________________

City:  

________________________

State:  

________________________

ZIP:

__________________

Country:  

________________________

Telephone:  

_________________________________________________

Ship To:  (If different then above)

Name:  

__________________________________________________

Address:  

______________________________________________________________

City:  

________________________

State:  

________________________

ZIP:

___________________

Country:  

________________________

Telephone:  

__________________________________________________

 

Payment Options:  (Select One)

Money Order (Amount):

VISA:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration Date: (MM/YY) Security Code: _______(on signature Strip)

MasterCard:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration Date: (MM/YY) Security Code: _______(on signature Strip)

Discover:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration Date: (MM/YY) Security Code: _______(on signature Strip)

If paying by credit card, please sign below:

Signature:_______________________________________

Date:______________

Item #

Description

Color

Size

Qty.

Unit Price

Total Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Shipping is handled on a flat rate of $9.50 for UPS Ground or call for 2nd & 3rd Day Air. 

Boards require special rates, please call for details.

Shipping & Handling*

 

Sales Tax (Florida residents only)

 

 Grand Total

 

Contact Information:

Telephone: (321) 777-5936          Fax: (321) 777-9058
Address: 131 Tomahawk Drive, Unit #25, Indian Harbour Beach, Florida, USA   32937
e-mail: Rain@RDistributing.com