Order form

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MESMERIZE Order form

You may use this form on-line and submit your details, or print out the form and send it via mail including cheque, credit card details or money order to:

Mesmerize, 26 Wellgate, Rotherham, South Yorkshire, S60 2LR, England.

Please enter the Order Codes, Descriptions and quantities of the items that you require. If you need more space, please re-use this form a second time filling in the full total on the 2nd form.

ORDER CODE

DESCRIPTION

QTY

PRICE EACH

TOTAL

UK postal charges: Ł3 orders up to the value of Ł20, Ł4 on orders Ł20-30, 10% on orders Ł30+ For more details, click highlighted blue text ------->> Post & packaging

Total (In UK pounds)

Any Comments, or other information

To finish your order place your details below. If you would prefer to phone or fax your credit card details then we can be contacted on (01709) 821 403 in the UK or +44 1709 821 403 overseas.

Method of payment ( If you are paying for your goods by a non card method, please print off this page and post with your payment ) If you are paying by credit card you can print off this page, & fax it to us if you would prefer as we now have 24 hr fax service on 01709 821403
Payment method
Card type
If you would prefer us to phone you for your card number, please tick here and fill in your phone & address details below
Card holder name
Card number
3 digit security code	this is the last 3 numbers on your signature strip
Expiration date	or valid from date
If you are paying by switch or solo we also need the issue number

Please remember that the address that you use has to be the card holders address (the one registered with the credit card company). We are unable to send the goods to a different address. Please provide the following contact information for the delivery of your goods *Required fields

First name *

Last name *

Title (e.g Mr, Miss)

Street address *

Address (cont.)

Town/City *

County/State

Postcode/Zip *

Country *

Home Phone (and best time to ring)

E-mail *

Once you have completed your Order, press Submit Form, or to clear your Order and re-submit, press Reset Form. Thank-you for choosing to shop with MESMERIZE.

Copyright : Mesmerize, 2000 Last revised: March 26, 2008.

Copyright : Mesmerize, 2000
Last revised: March 26, 2008.