Printable Fax or Mail Order Form for Visa, MC, Discover, and AMEX

Fax and mail ordering isn't currently available however you may order on our website www.air-purifier.org with a credit card or eCheck.

Shipping and Contact Information
Name: Phone (        )        -
Street:
City: State: Zip: Country:
Email (for order confirmation): Fax#:

Product Information
Qty Item Description Color (Black or White) Price Each Subtotal
Subtotal
Shipping
FREE for orders over $33!
TOTAL
Billing Information
Check one: VISA MC DISCOVER AMEX
Credit Card Number:               -               -               -                  Expires M/Y:          /
CVV2 Code (3 digits on back of VISA, MC, DISC or 4 on front of AMEX):
Name on Card:                                                                        Phone (        )        -
Credit Card Billing Address (where statements are mailed - check here (   ) if same as shipping address)
Street:
City: State: Zip: Country:
Signature: Date:

Thank you for your order!

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