Unitedshades.com : Blank order form

Blank order form

Don't feel safe entering your personal information on the Internet? Fill in the form below, print it out and fax it to:
Rome, Italy (h.q.)	+39 06 2441 8945
New York City	1 212 656 1348
USA Toll-free	1 888 366 8703

ENTER HERE YOUR PURCHASE DETAILS (bold fields are required)
Brand name
Model #
Color #
Size

ENTER HERE YOUR SHIPPING ADDRESS (bold fields are required)
First name
Last name (Surname)
Address *
	* no P.O. Box accepted as shipping address
City
State
Postal Code
Country
E-Mail Address
Phone Number **
	** please include city/area code
Fax Number
Special instructions
Special offer coupon #

YOUR SHIPPING METHOD

We can ship from ITALY by:

Federal Express
Priority Air Mail

Click here for more details about shipping and Federal Express tariffs.
(Important information. Please read if it is your first time you buy from us.)

ENTER HERE YOUR CREDIT CARD DETAILS
(bold fields are required)

Credit Card

Visa

Mastercard/Eurocard

American Express

Card number

Exp. Date

Cardholder First Name

Cardholder Last Name

Card security code [?]

ENTER HERE YOUR CREDIT CARD BILLING ADDRESS (bold fields are required)
Your credit card billing address is the address where you receive your monthly statement.
Street Address
City
State
Postal code
Country
Phone
	^{[please include city/area code]}