FAX ORDER FORM

Print this page, fill in the information and FAX to:

  (516) 931-0302

Name: _____________________________________________________________

Address: ___________________________________________________________

City: __________________________ State: ____ Zip: ______ Country: __________

Phone: Required (____)____ - _________ Email Address: ______________________

Payment (circle one): Money Order | Visa | Mastercard | American Express | Discover

Name on Card: ___________________________ Expiration Date: ___/___ (month/year)

Card Number: ___________________________________ CVC#: __ __ __ __
CVC: This is the number on the back of your card on the strip where you sign. It is a 3-digit number and may follow a longer number. On American Express Cards, it is a 4-digit number on the front of the card. We require it for added security.

Signature: __________________________________________________________
Credit card purchases only

Delivery Options: (circle one)   UPS     CVFI Delivery     Customer Pickup