FAX ORDER FORM      Fax 310-541-3087
J.P.I. Inc.
927 Deep Valley Dr, Suite 299
Rolling Hills Estate, CA 90274, USA

Date:                           

Print out this form, fill it in,
and fax to 310-541-3087

- Please write in print - Please write in print - Please write in print -
Product # Quantity Product Name Price Each Total
         
         
         
         
         
         
         
We will process your payment after we reconfirm your order by sending back a complete form including shipping/handling fee and tax by fax.  Just sign on the form and send it back again to us by fax if you accept the total cost.  Please make sure you provide your fax number in this form.   Fax to  JPI Inc   310-541-3087

Thank you for doing business with us.

Subtotal

 

S/H

 

Tax

 

Total

 

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Your Name                                                Email Address                                   
Daytime Phone                                           Fax Number                                      

Billing Address

  Street                                                                 City                                                  

  State/Province                            Country                        Zip/Postal Code                    

 Card Information

  Card : _________   NO: _______________________________   Exp: ______________

  Card Holder Name : __________________________________________
 
  Signature : ________________________________  Date: ___________________________
 
Shipping Address ( If different from Billing Address )

  Street                                                                 City                                                  

  State/Province                            Country                        Zip/Postal Code                    

Signature                                                   Date                     

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