Fax Order Form
Talaria Enterprises
PO Box 1585
Glendora, CA USA 91740
(800) 227-9196, (909) 599-6434
(309) 210-7477 fax

Contents:

• Section 1: Bill-To Information
• Section 2: Payment Information
• Section 3: Ship-To & Order Information
• Section 4: Comments

Mr.____ / Mrs.____/ Ms. ____

First Name:________________Last Name: ________________________________

Address1:____________________________________________________________

Address2:____________________________________________________________

City:______________________State/Province:____________ Zip:____________

Country: _________________________ Email: ______________________________

Phone: ___________________________ Fax: _______________________________

Payment Method: Mastercard ___/ VISA ___/ AMEX___/ Discover____/
Check or Money Order ___/
Note: If pre-paying by check, send payment to Talaria Enterprises, PO BOX 1585 Glendora, CA 91740 USA.

Credit Card #: _______________________________ Expiration: ____________

Name on Card: _______________________________________________________

Please sign:____________________________________________________________

Please send the following order:
Is the Ship-to address the same as the Bill-to address? Yes___ / No___
(If yes, leave this section blank.)

Mr.____ / Mrs.____/ Ms. ____

First Name:________________Last Name: _________________________________

Address1:____________________________________________________________

Address2:____________________________________________________________

City:______________________State/Province:______________ Zip:___________

Country: _________________________ Email: _____________________________

Phone: ___________________________ Fax: ______________________________

Comments:____________________________________________________________

Please enter any special instructions here. If you would like a gift card included at no charge with your order, please enter the Gift Message here.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Thank you for ordering from Talaria Enterprises!

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