ORDER FORM

Visit the Crucible Catalog for unusual and hard-to-find esoteric items!

To mail or fax your order, print this form. To place your order by phone or FAX, call toll-free (877) 782-7389.

Name: _____________________________________________________________

Address: ___________________________________________________________

City: ______________________________ State: _______ ZIP: ________________

Country: ___________________________________________________________

Telephone: (         )________________ Email: ______________________________

If paying by Visa or MasterCard, please enter :  Expiration Date: _____/___________

Card Number: _______________________________________________________

Signature: __________________________________________________________

Item# / Description

Quantity

Price Each

Item Total

       
       
       
       
       
       
          
                                                                                                      SUBTOTAL    

California residents add 7.75% Sales Tax.(Multiply SUBTOTAL by .0775)  CA TAX

 

$10.00 FLAT SHIPPING CHARGE (Outside US/Canada: $20 flat charge)                                                                                                      SHIPPING 

 

                    Universal Currency Converter                    TOTAL

 

     Fax this completed order form toll-free to (877) 782-7389 or mail with your payment to:       

    ETX, Box 22201, Sacramento, CA 95822-0201 USA

 

 

 

 

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