Printable Fax/Mail Order Form for Visa, MC, AMEX, Discover, Check, or Money Order

If paying by check, please include your driver's license number on your check!

Mail: 
Timeless Treasures
3761 Brownlea Rd
Silsbee, TX 77656
Fax: 
   (409)386-0442

Ship To
Name:  Phone  (       )         -
Street:
City: State: Zip: Country:
Email: Fax#:
Products
Qty
Item Number, Size and Color
Price Each
Subtotal
       
       
       
       
       
   
Subtotal
 
Shipping - (See Chart Below) U.S. Only
 
TOTAL
 
Shipping Chart
Purchase Amount Shipping Cost Purchase Amount Shipping Cost
Up To $50.00 $5.95 $250.01 - $300 $12.95
$50 - $100 $6.95 $300.01 - $350 $14.95
$100.01 - $150.00 $7.95 $350.01 - $400 $16.95
$150.01 - $200 $8.95 $400.01 - $450 $18.95
$200.01 - $250 $10.95 $450.01 - $500 $20.95
Billing Information
Circle One:
VISA MC AMEX DISCOVER
Credit Card Number:               -               -               -                  Expires M/Y:          /                                    CVV2 Code:         
Name on Card:                                                                        Phone  (       )        -
Credit Card Billing Address (where statements are mailed)
Street:
City: State: Zip: Country:
Signature: Date:

Thank you for your order!

© 2002 http://www.timelesssilver.com