Lid Factory
1000 Park Avenue
Cayucos CA 93430
USA
Phone/Fax 805-995-2628
 		 Fax Order Form
Complete this form, then select File, Print
Fax printed copy of this order form to 805 995 2628
 
 

            Bill To:

Ship To: (leave blank if same as Bill To:)

  
  First Name: First Name:  
  Last Name: Last Name:  
  Company: Company:  
  Address1: Address1:  
  Address2: Address2:  
  City: City:  
  State/Province: State/Province:  
  Postal Code: Postal Code:  
  Phone: Phone:  
  Country: Country:  
  E-mail Address: E-mail Address:  

Payment, Product, Shipping Options
 

Product Description

Quantity
# Cartons

Price
per Carton

Total
Credit Card Type:
Credit Card#
Card Holder Name:
Exp. Date (mm/yy)  

Subtotal:
Card Security Code:     3 or 4 digit code on back of credit card Shipping Handling:
Shipping Method: Grand Total:
Shipping Instructions:
  Yes, I authorize Lid Factory to charge to my credit card all orders shipped to any of the above addresses:  
  I will be purchasing universal inkjet cartridge seals from Lid Factory, under the terms and conditions published by my credit card company.  
 
Cardholder signature:  ______________________________________          Date:  _____________