FAX ORDER
ORDER FORM: AUTOMATIC CHICKEN COOP DOOR OPENER
Please charge my card $184.94 + $22.00 Shipping (USD)
Shipping Information:
| First Name | _______________________________ |
| Last Name | _______________________________ |
| Address | _______________________________ |
| _______________________________ | |
| Zip Code | _________ |
| State | ______ |
| Phone Number | ______________________________ |
| Email Address | ______________________________ |
| Credit Card Details |
Circle One Below |
| Type Of Card | (Visa) (Mastercard) (American Express) |
| Name On Card | __________________ |
| Card Number | __________________ |
| Expiry | _________ |
| CVV # On Back | _________ |
Print This Form..
Fax It To: 219-979-9149
