Tyless TM Fax, Mail
Order Form
Ship To: Bill To: (If Different)
Name: ___________________________________________ Name: _____________________________________________
Company: _________________________________________ Company: __________________________________________
Address 1: ________________________________________ Address 1: _________________________________________
Address 2: ________________________________________ Address 2: _________________________________________
City: ______________________________________________ City: _______________________________________________
State: _______ Zipcode: __________________________ State: ______ Zipcode: _____________________________
Email Address: ___________________________________ Telephone: __________________________________________
Name: ___________________________________________ Name: _____________________________________________
Company: _________________________________________ Company: __________________________________________
Address 1: ________________________________________ Address 1: _________________________________________
Address 2: ________________________________________ Address 2: _________________________________________
City: ______________________________________________ City: _______________________________________________
State: _______ Zipcode: __________________________ State: ______ Zipcode: _____________________________
Email Address: ___________________________________ Telephone: __________________________________________
If paying by credit card, please provide Credit Card information below. MC, Visa, AMX, Discover accepted
Credit Card Number: _________________________________________________ Credit Card type: ______________
(MC, Visa, AMX, Discover)
Credit Card Expiration Date: _________________________ Fax To Tyless at: 541-344-1579
Amount Authorized: _______________________ Mail to Tyless at: Tyless
P.O. Box 11205
Eugene, OR 97440
Signature: _________________________________________
Orders with personal checks will ship after check
clears bank.
(MC, Visa, AMX, Discover)
Credit Card Expiration Date: _________________________ Fax To Tyless at: 541-344-1579
Amount Authorized: _______________________ Mail to Tyless at: Tyless
P.O. Box 11205
Eugene, OR 97440
Signature: _________________________________________
Orders with personal checks will ship after check
clears bank.
Pricing:
Length of Cord
Number
of
Cords
Prices shown are total cost including shipping & package
Length of Cord
Number
of
Cords
Prices shown are total cost including shipping & package
|
Color Quantity
Cord Length __________________
Number of Cords __________________
Number of Cords __________________
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