Printable Product Order
PLEASE PRINT CLEARLY
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Products & Services Order
I Hereby Order:
Name or Product Code of item/s ordered:
1. __________________________________Price US$_ _ _ _
2. __________________________________Price US$_ _ _ _
3. __________________________________Price US$_ _ _ _
4. __________________________________ Price US$_ _ _ _
(use another sheet of paper for more items.)
5. Courier Delivery (if any,) plus (US$ 60.00)
6. Total order-----------------------------------------US$_ _ _ _ _ _ _
7. Your Name: ____________________________________________
8. Address to ship to: ___________________________________
9. City __________________________
10. Postal Code ____________
11. State/country ________________
12. Country _________________
13. Tel. (Only in reference to order,) area code _______________ Number _____________________________
14. Fax number: ____________________
15. E-mail address: _______________________________
16. Check one:
Payment by [ ] Bank Wire - [ ] Western Union - Egold - [ ] Paypal - [ ]
17.Signature
_____________________________
18. Any Special Instructions/requests
_________________________________________________________ ______________________________________________________________________________
19. Please include your e-mail address or fax number in case we need to contact you about this order.
______________________________________________________
For fastest service a bank-to-bank wire, Egold, Paypal or western union sent via secured e-mail is recommended.
send scanned by e-mail to : offshore-ultimate@hush.com
