ROTEM - ORDER FORM

Please fax completed form to: 562-795-5525

Date Faxed: ____________________

ORDER/ITEM INFORMATION:

ITEM #: ____________________ QTY: _______
ITEM #: ____________________ QTY: _______
ITEM #: ____________________ QTY: _______

Text on Greeting/Gift Card (if any):

________________________________________

________________________________________

Signed: __________________________________

SHIPPING INFORMATION:

Full Name:___________________________________
Address-line 1:________________________________
Address-line 2:________________________________
City:________________________________________
State:________________________
Province/Region:______________________________
Zip/Postal Code:_______________________________
Country:______________________________________
Phone Number:________________
eMail Address:_________________________________

Shipping Method (Circle One): Free UPS Ground UPS 2-day UPS Next Day

BILLING INFORMATION:

Credit Card Type (Circle One): Discover Visa Mastercard American Express

Card Number: _____________________________________
Expiration Month / Year: _______ / _________

If shipping information is different from billing
information as listed with your credit card company,
please complete the following:

First Name:___________________________________
Last Name:___________________________________
Company Name:______________________________
Address-line 1:________________________________
Address-line 1:________________________________
City:________________________________________
State:________________________
Province/Region:______________________________
Zip/Postal Code:_______________________________
Country:______________________________________
Phone Number:________________
eMail Address:_________________________________

Any comments or message for us?
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