Email : _____________ @ ______ . ______ (Required if you are FAXing)
Credit Card FAX or EMAIL Form
To: EBulkCandy.com
FAX (215) 392-4340
Email: info@eBulkCandy.com
Please Check Statement if Applicable
____ I have received an Order Quote email and would like my order processed and my credit card charged now.
____ I would like an Order Quote email to review total cost of the order before processing. I may choose to accept the total cost via return email and you may then charge my credit card.
______ I am emailing my credit card information and am sending the last several numbers and the expiration date in a seperate email.
Items and Quantities Ordered:
Total Price of Order: $ _______
CREDIT CARD TYPE:
___ VISA ___ MASTERCARD ___ AMEX
____DISCOVER
CREDIT CARD NUMBER:
___________________________
Expiration Date ____/_____
I am the cardholder of the card submitted in this form and I authorize my card to be charged for the Order Total.
