Moccasin Smart FAX or MAIL Order Form

Moccasin Smart FAX or MAIL Order Form

Complete this order online, print and fax to 1.215.355.4919
This form may also be mailed to:
Moccasin Smart
535 Andrews Rd., Suite 100
Trevose, PA 19053

First Name
Last Name
Company
Street Address or PO Box
City
State (Optional if outside of USA)
Zip/Postal code
Country (if other than USA)
Phone
Fax
E-mail

QNTY	PRODUCT #	DESCRIPTION	PRICE	TOTAL









SUBTOTAL
SHIPPING & HANDLING (See Below)
TOTAL

SHIPPING & HANDLING

UPS GROUND INSURED
$8.95 for orders under $75.00
FREE Shipping and Handling for orders over $75.00

METHOD OF PAYMENT

Credit card type

Cardholder full name & billing address (if different from above)

Card number (with dashes)

Expiration date (mm/yy)

CCV
(Card Code Verification) This is the three-digit code located after the credit card number on the signature strip of Visa, Master Card, and Discover cards. American Express cardholders can locate a four-digit code on the front of the card above the account number.

Special Instructions?

QNTY