Please print out the form below, and neatly fill in
the information requested.
Fax form with credit card information to:
(707) 202-3540 or
Make checks payable to
CSA Worldwide and Mail to:
CSA Worldwide,
1015 Gayley Avenue, #1137
, Los Angeles, California 90024
BILLING INFORMATION How did you hear about us? _____________________ |
|||
|---|---|---|---|
Name/Company |
_________________________________ | Date |
______/______/______ |
Street Address |
_________________________________ | ||
City/State |
_________________________________ | Zip Code |
__________________ |
Day Phone |
(_______)________________________ | Evening Phone |
(_______)________________________ |
Fax # |
(_______)________________________ | ____________________________ | |
SHIPPING INFORMATION |
|||
|---|---|---|---|
____ |
Ship to Billing Address | ____ |
Ship to Address Below |
Name/Company |
_________________________________ | ||
Street Address |
_________________________________ | ||
City/State |
_________________________________ | Zip Code |
__________________ |
CREDIT CARD INFORMATION - Make sure your credit card information is entered correctly. |
|||
Type of Credit Card (circle one) |
Card Holder Name |
_______________________________________ | |
Mastercard Visa American Express |
Card Holder Signature |
_______________________________________ | |
| Credit Card Exp. Date | __________ | Credit Card Number |
_________ - _________ - ________ - _______ |
| ORDER INFORMATION | ||||
|---|---|---|---|---|
ITEM NUMBER |
DESCRIPTION |
QUANTITY | PRICE EACH |
TOTAL PRICE |
| . | . | . | . | . |
| . | . | . | . | . |
| . | . | . | . | . |
| . | . | . | . | . |
| . | . | . | . | . |
| . | . | . | . | . |
MERCHANDISE TOTAL |
$ | |||
| SHIPPING CHARGES GROUND SERVICE (DOMESTIC, U.S.A.) | 8.25% SALES TAX |
||
| IF MERCHANDISE TOTAL IS: | CA RESIDENTS ONLY |
_______________ | |
| $00.00 - $29.99 | ADD $6.00 | ||
| $30.00 - $39.99 | ADD $7.00 | SHIPPING CHARGES |
|
| $40.00 - $57.99 | ADD $8.00 | USE CHART AT LEFT |
_______________ |
| $58.00 - $99.00 | ADD $9.00 | ||
| $99.01 and Over | ADD $11.00 | ORDER TOTAL | $______________ |
| BACK HOME | ORDERS CALL 800-807-2566 | SECURITY INFO |