Order & Credit Card Information Form

Complete this form with check made out to: Extreme Supply      Fax or mail to:
Extreme Supply - 2650 E 28th St - Signal Hill, CA 90755 USA - FAX: (562) 595-1113

Daytime Telephone Number (very important!) ______________________

FAX Number (if you have one) ______________________

Email Address _____________________________________
(very important; please print clearly!)

Credit Card Information:

 __ Visa   __ MC  __ AMEX  __ Discover  __ Check or Money Order 

Name on Card_____________________________________________________

______________________________________________  __________
Credit Card Number (13-16 digits)               Exp. Date                   

Billing Information

Name ____________________________________________________________

Address__________________________________________________________

City, State _____________________________________________________

Zip/Postal Code, Country ________________________________________

Shipping Information(if different from above)

Name ____________________________________________________________

Address__________________________________________________________

City, State _____________________________________________________

Zip/Postal Code, Country ________________________________________

                Description                   Qty.  Price   Total

____________________________________________  ___  ______  ______

____________________________________________  ___  ______  ______

____________________________________________  ___  ______  ______

                                               Sub-Total   ______

                          Shipping(Please see info page)   ______

       Tax(if shipped to CA put 8.25% of Sub Total here)   ______

                                                   Total   ______
__________________________________ 
Signature(required)