Your Name: | _______________________________________________ |
Company: | _______________________________________________ (optional) |
Street Address: | _______________________________________________ _______________________________________________ |
City or Town: | _______________________ |
State or Region: | _______________________ |
Phone Numbers: Please include c area code |
Daytime: ________________ Evening: ________________ |
Email address: Required for delivery |
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Credit Card Details | |
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[ ] VISA [ ] MasterCard [ ] AmericanExpress [ ] NOVUS/Discover |
Credit Card Number: | ________________________________________ |
Expiration Date: | Month: ____________ Year: ____________ |
Amount: | $ ____________ . ___ U.S. Dollars |
Cardholder's Name: | _______________________________________________ |
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In order to avoid losing your info, If you have problems submitting your form, ( for example you get a message: "oops! must be a tripod website" ) after you receive the oops message, just click the "back" button and complete the missing information - if you still receive an oops message, you may want to just print the completed form and mail it to: xkr essex, inc. 2911 e. vista st. #C long beach, ca 90803