Order & Credit Card Information Form

Complete this form and fax or mail it to: The Bell Store (powered by Extreme Supply)
2650 E 28th St - Signal Hill, CA 90755 USA - FAX: (562) 595-1113

Daytime Telephone Number (very important!) ______________________

FAX Number (if you have one) ______________________

Email Address _____________________________________
(very important; please print clearly!)

Credit Card Information:

 __ Visa   __ MasterCard  __ Check or Money Order 

Name ____________________________________________________________

______________________________________________  __________
Credit Card Number (13-16 digits)               Exp. Date                   

Billing Information

Name ____________________________________________________________

Address__________________________________________________________

City, State _____________________________________________________

Zip/Postal Code, Country ________________________________________

Shipping Information(if different from above)

Name ____________________________________________________________

Address__________________________________________________________

City, State _____________________________________________________

Zip/Postal Code, Country ________________________________________

           Description            Color/Size  Qty.  Price   Total

________________________________  __________  ___  ______  ______

________________________________  __________  ___  ______  ______

________________________________  __________  ___  ______  ______

                                                SubTotal   ______

       Click on Shipping & Non-USA Orders at top of page   ______

      Tax(if shipped to CA, put 9.00% of Sub Total here)   ______

                                                   Total   ______

__________________________________ 
Signature(required)