Double D Western World

Fax Transmittal for Internet Order

TO: Double D Western World Fax: US 928-684-3051

FROM: _______________________________________________ Fax: _________________________________

Email: _______________________________________________ Telephone: ____________________________

RE: __________________________________________________ Date: ________________________________

Please submit my order for the following:

Ship to:
Name __________________________________________________________

Address (physical) ________________________________________________

City and State (Prov)______________________________________________

Country ________________________________ Postal Code______________

Credit Card Information:

Number: _____________________________________ Exp Date: __________

Exact name on credit card: _________________________________________

Type: VISA MC AMEX DISCOVER

Signature of purchaser ______________________________________________________