--------- Del West's Market Market ORDER FORM --------- http://www.mktmkt.com Tel/Fax: 858 689-9999 email: delwest@mktmkt.com ------------ POS Products PCAuthorize ICVerify MacAuthorize ------------- ---------------------------------------------------------------------------- FAX ORDERS: Fax machine - simply print out this form then fill in info. Fax/modem - "save to file" this form, and input info w/text editor. Then send fax by computer modem. Fax: 619 689-9999 TEL ORDERS: Del West at (619) 689-9999 MAIL ORDERS: Print out this form then fill in info. Credit card or check O.K. To: Del West, 10415 Summerwood Court, San Diego, CA 92131 Ship to: Customer Name: __________________________________________________ Address: ___________________________________________________________ City: _______________________ State/Province:_____________________ ZIP/Postal Code ________________________ Country:_________________________ Telephone: __________________________ Fax:__________________________ E-mail Address: __________________________________________________________ Credit Card Info: VISA MC AmEx Discover (circle one) Credit Card Number: _____________________________ Exp.Date:_____________ Name Associated w/Card: _________________________________________________ Street/PO Box Associated w/Card:__________________________________________ Zip Code Associate w/Card:________________________ Bank or Company Issuing Card:_____________________________________________ Quantity Item Price _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________ If California destination....add sales tax 7.75%_______________ *Shipping_________________ Total Price__________________ *USA: FREE 2-Day UPS/FEDERAL EXPRESS Shipping *Canada: FREE 5-Day UPS or Add $35 for 2-Day FED-X Shipping