Please fill out all sections of this form and mail (to address below) or FAX it back to us at 1-707-762-8305 we will process your order. All information is kept confidential.:
All prices in US $ dollars
First and Last Name:_______________________________________________
Street.:_________________________________________________________
City:___________________________________State:_____Zip____________
Country:________________________________________________________
Email Address:___________________________________________________
Phone:_________________________________________________________
FAX Number.:___________________________________________________
Visa exp date_______ Master Charge exp date______ Discover exp. date_____
Credit Card #______________________________________________
Signature_________________________________________________
Item number______ Item Name_______________________ Price___________
Item number______ Item Name_______________________ Price___________
Item number______ Item Name_______________________ Price___________
*(7/3/03)*******************Sub Total_____________________________
************California Residents add 7 .50% sales tax___________________
Total Charges____________________________________________________
Print this page and fill out the needed information and FAX the form to 1-707-762-8305 or mail this form to Rocklin Jewelry 9 Western Ave. Petaluma, CA. 94952
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