PRINT THIS FORM TO ORDER
[___] I have read and accept terms of sale
[___] For best service, we request that all NEW
customers call and speak to us on their first order
so that we can best match the correct product to your needs.
Please provide ALL information requested, print this form and submit to us by Fax, Mail or Email:
Wegner Crystal Mines PO Box 205, Mt. Ida, AR 71957
Phone/Fax 1 870 867-2309 or Order Line 1 800 367-9888
Website www.wegnercrystalmines.com
DATE__________
NAME _____________________________ PHONE______________________EMAIL_________________
BUSINESS NAME_______________________________________________________________________
STATE ISSUED RESALE TAX ID #____________________________________________________________
SHIP TO ADDRESS (STREET)_______________________________________________________________
CITY___________________________________STATE__________ZIP______________
COUNTRY_____________________
SHIP THIS ORDER ( ) UPS GROUND 5-7 DAYS
( ) UPS 3 DAY SELECT
( ) UPS 2ND DAY AIR
( ) UPS NEXT DAY AIR
( ) UPS INTERNATIONAL AIR
( ) OTHER (please specify)
*NO P.O. ADDRESSES FOR UPS ORDERS
*UPS INSURANCE- UNDER $100 IS FREE
OVER $100 = .70 PER $100 - $2.10 MIN.
*UPS COD FEE $10.00 *MINIMUM ORDER $100.00 MERCHANDISE *RUSH ORDER - ADD 10%
QUANTITY |
DESCRIPTION (FROM OUR CATALOG) |
PRICE/# |
ITEM TOTAL |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
TOTAL |
|
WE ACCEPT PAYMENT BY CHECK, MONEY ORDER OR MAJOR CC’s: Mastercard, Visa, Discover & AMEX
Name on Card:________________________________
Card Number: ________________________________
Expiration Date:_______________________________
Security Code: (3-4 digits on back)________________
WEGNER CRYSTAL MINES
CREDIT CARD AUTHORIZATION
COMPANY NAME:______________________________________________________
NAME ON CARD:_______________________________________________________
TELEPHONE:_________________________________FAX:_____________________
IS CARD BILLING ADDRESS DIFFERENT THAN SHIP TO? ___________________
IF SO, BILLING ADDRES_________________________________________________
WITH SIGNATURE, I HEREBY AUTHORIZE VENDOR TO KEEP ON FILE FOR THIS AND FUTURE PURCHASES THRU________________________ (Insert Date to Maintain on File) Sign________________________________Print____________________________
(Must be the same name as on card above) Print & Sign your name.
OR:
AUTHORIZED SIGNATURE FOR THIS PURCHASE ONLY:
Sign___________________________________Print___________________________
(Must be the same name as on card above) Print & Sign your name.
Date:_____________