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Order Form Four Points Gem


Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Please provide the following product information:

Product Name
Stock number  
Description     
Size and Color

Please provide the following ordering information:

QTY DESCRIPTION

BILLING
Credit Card
Cardholder Name
Card Number
Expiration Date Security Code

The Date should be input as mm/yy

Security Code is on the back of your card. The last 3 digits.

SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Author: Alan R. Thackrah.
Copyright 1999 [Four Points Gem Illuminations]. All rights reserved.
Revised: -->August 26, 2002 -->