Monroe Enterprises
FAX/MAIL Order Form

Print this form, complete it and fax to (775)418-6031

PO Box 143

Upperstrasburg, PA 17265

717-491-1065

 

Ordered by
Your Name ________________________________________

Phone Number____________________

Address ______________________________________________

City _______________________ State _____ Zip _____________

Ship to (write "same" if same as above) ________________________________________

Address ______________________________________________

City _______________________ State _____ Zip _____________

 

Card Type (circle one) MasterCard ---Visa---American Express---Discover

Credit card number _______________________________ Exp. Date _______________

Product_____________________ Quantity__________________ *Shipping______________ Total_____________

Product_____________________ Quantity__________________ *Shipping______________ Total_____________

 

Grand Total ______________

*Please include $5.00 shipping and handling per tape.
 

If you are a Pennsylvania resident, please add 6% to your total.

Signature (as it appears on credit card) _____________________________________

Return: to BlackIndians.com, Inc. Home Page
_______________________________________________________________________________
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PO Box 143