Time Machine Purchase Order

If your Fax does not send on the first try, Please Try Again Immediately!
Fax will automatically pick up by the second try.
In order to process your credit card order, we need the following information.
Please print this form, fill out COMPLETELY and fax to 618-423-9709

Please Print Clearly!

Date: ________/________/________

Your Name (as it appears on your card): ________________________________________________

Street Address (must match address on credit card):


City: ______________________________________

State: __________________________  Zip ___________________________

Phone # including area code: (__________)_______________-_____________________

Your email address: __________________________________________

Stock # Description Price

UPS Ground Shipping
(Rates apply to Contintental USA)

Charge to my: (circle one)   VISA    MasterCard

Card Number: ______________________________________

Expiration Date: __________/__________

CARD CODE #: _____________  (Last 3 Numbers Found On Signature Line On Back Of Card...REQUIRED)

I hereby authorize this transaction:

Signature: _____________________________________________________

Thanks for your order!
(863) 699-0320