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Fax Order Form |
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To fax us an order, please print this blank form using your Browser. Complete the form and fax the completed form to 1-817-549-1037
If you wish to place a phone order instead or have any questions, please call us toll free at 1-866-432-4936 or send an email to service@myjewelrysource.com. |
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Item # |
Brief Description |
Gold (w/y/14k/18k) |
Cost |
Size |
Sizing Fee |
Total |
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USPS Priority Mail (all order totals under $250):
UPS Ground:
UPS 2nd Day: $6.50
Special Instructions: Gift Card Message: |
Subtotal: |
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We pay your CA Sales Tax: |
0.00 |
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Shipping (see chart at left): |
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Total: |
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| Customer Billing Address: | Shipping Information (skip if same as billing) | ||
| Name: | _____________________________ | Name: | _____________________________ |
| Address: | _____________________________ | Company: | _______________________(if applicable) |
| _____________________________ | Address: | _____________________________ | |
| City: | _____________________________ | _____________________________ | |
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State: |
_____________________________ | City: | _____________________________ |
| Zip: | _____________________________ |
State: |
_____________________________ |
| Phone: | _____________________________ | Zip: | _____________________________ |
| Email: | ______________________ (optional) | ||
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Payment by Credit Card: |
Circle One: |
VISA Master Card American Express Discover |
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Credit Card Number: |
_______ _______ _______ _______ Expiration:___/___ |
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_________ Visa, MC: last 3 digits on signature strip | Amex: 4 digits on front of card |
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Name as it appears on the card: |
_________________________ |
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Signature: |
_________________________ Date: _____________ |
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