Flagship Distributors FAX Order Form
			Fax No: (619) 491-0453

Please PRINT the form first, complete the necessary information, and FAX to (619) 491-0453.

Customer Information:

Purchasing Agent:_______________________       DATE :________________

PHONE:_______________  FAX:________________    EMAIL:________________

Purchase Order # _____________  Credit Card:  Master Card  __  Visa __

Credit Card #:___________________________ Expiration Date:____________

VCode: ____  (Last 3 digits at back of card on signature area.) 

Date Delivery Required: ____________________

Billing Address:	          Atten: _________________________

		           Name/Company: _________________________

		               Address:  _________________________		

			City/State/Zip:  _________________________


Shipping Address:         	   Atten: _______________________

		            Name/Company: ________________________

		               Address:   _________________________

		
			City/State/Zip:   _______________________
 

 Quantity	   Description	       	     Unit Cost    Ext. Cost      
||______||________________________________||___________||__________||

||______||________________________________||___________||__________||

||______||________________________________||___________||__________||        	

||______||________________________________||___________||__________||

||______||________________________________||___________||__________||
								  
	Shipping UPS (under 2lbs, Continental US only) ||__ 9.00 __||
     
			                        Total  ||__________||

Check with us for shipping cost to Alaska, Hawaii and International.
Shipping costs will be modified for heavier packages. Request for 
approval will be emailed prior to shipping.

		Flagship Distributors 		ph: 1-800-25-FLAGS
		3921 Fourth Ave
		San Diego, CA 92103-3109
								
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