PLEASE CHARGE MY ORDER, INCLUDING SHIPPING CHARGE TO:
SELECT ONE: _____VISA _____MASTER CARD
CARD HOLDER:________________________________________________________
(PLEASE PRINT NAME AS IT APPEARS ON CARD)
CREDIT CARD #:_______________________________________________
V-CODE ____________________
(ON BACK BY SIGNATURE LINE)
EXPIRATION DATE:_______________
AMOUNT $_______________________(Plus Shipping)
MONTH/YEAR
(ALL PAYMENTS IN U.S. DOLLARS)
CREDIT CARD BILLING ADDRESS:
__________________________________________________________________________________________________
ADDRESS
CITY
STATE
ZIP CODE
COUNTRY
SHIP TO ADDRESS: ( If item is being shipped to a business please provide Business Name w/ address)
_______________________________________________________________________________________
NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
SIGNATURE:__________________________________DATE:________________
I have read and agree to Alpha Water Systems Inc Return Policy.PHONE NUMBER:______________________________ E-MAIL:__________________________(For Order Confirmation)
ITEMS ORDERED:_______________________________________________________________
____________________________________________________________________
PLEASE FILL OUT THIS FORM AND FAX TO: (973) 293-8056. THANK YOU.