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Fax Order Form

To place an order via Fax, print this form, fill in the required information, then fax it to (816) 587-2055, anytime day or night. (All fields in Orange* are required.)

BILL TO: Company Name* _______________________ Contact Name*  _______________________ Contact Phone Number* ________________ Contact Email ID ______________________ Mailing Address* _______________________ City* ___________________ State* __________________ Zip* _________	SHIP TO: (if different than billing) Company Name _______________________ Contact Name  _______________________ Contact Phone Number ________________ Email  ______________________________ Mailing Address _______________________ City ___________________ State __________________ Zip _________
PAYMENT METHOD (circle one) Pay by* Check   Credit Card   Money Order	Purchase Order Numer (if applicable) ____________________________________
Type of Credit Card (circle one)      Visa     Mastercard     American Express     Discover	Credit Card # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date (mm/yy)  _ _ / _ _ CCV Code _ _ _ _
If paying by check make payable to Wear-Concepts, Inc, and mail to: Wear-Concepts Online Sales 106 NW Business Park Lane Riverside, MO 64150 (NOTE: Checks must first clear the bank before order is shipped.)

Item or Product ID	Description	Quantity	Price Each	Total
Product Total

Signature* _________________________________    Today's Date*  _____________