PLEASE PRINT OUT THIS FORM:
FAX:
(305) 675-2667
2577 W 80th St
Hialeah, FL (33016)
Note:
Billing address that do not match address of record with the card issuer bank may cause delay
in processing your order.
If you just moved, please provide your "Previous address".
Provide shipping information if different from billing.
Fields marked in
red
are
REQUIRED.
[Billing Information]
[Shipping Information]
* [First Name]
[Mi]
* [Last Name]
[First Name]
[Mi]
[Last Name]
* [Company Name]
[Company Name]
* [Street Address]
[Street Address]
* [City]
* [State]
* [Zip-Code]
[City]
[State]
[Zip-Code]
* [Phone]
[Fax]
[Phone]
[Fax]
* [E-Mail]
[E-mail]
[Add to mailing list ]
Payment Method:
Check must be pay to the order of :
X-Direct, Inc.
CHECK
VISA
MASTERCARD
AMERICAN EXPRESS
DISCOVER
Credit Card Number
(We need your exp. date and signature to ship your order.)
Expiration Date
Card Code (
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)
Signature: _____________________________________
Stock #
Color
Description
QTY
Unit
Total
TOTAL MDSE:
HANDLING:
SHIPPING:
FREIGHT SURCHARGE:
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FLORIDA RESIDENTS ONLY SALES TAX 7.0 %:
SUB-TOTAL:
BALANCE DUE:
NOTE: OUR CARRIERS WILL NOT DELIVERY TO P.O. BOXES, PLEASE PROVIDE US WITH AN ADDRESS.
Thank you for shopping with:
DRESSING HOMES an X-Direct, Inc Company.