12buys Fax Order Form

U.S. Fax: 1-707-885-1316 (West); 1-413-382-4484 (East)
Billing Information
Name :
Address Line 1 :
Address Line 2 :
City :   State :
Zipcode :  Country :
Tel :        Fax :

Shipping Information         Same As Billing Information
Name :
Address Line 1 :
Address Line 2 :
City :   State :
Zipcode :  Country :
Tel :        Fax :

Product List
Description UnitPrice (U.S.) Qty Total (U.S.)
Amount (U.S.) 

Other Information
Email :
*Please fill in your email address in order to get email confirm order from us
Payment : Visa Credit Card        MasterCard Credit Card        American Express Credit Card
MoneyGram                Western Union
Shipment : Standard (Free Worldwide Shipping)          Express (Additional Charge 35 USD)

Credit Card Information
Credit Card Number :
Cvv : Last 3 digits on rear of the card for Visa,Master. Last 4 digits on front of the card for Amex.     Click  More Detail  for detail
Card Holder Name :
Issuing Bank :
Expiration Month :
Expiration Year :
Card Holder Signature :
Please Place Card Holder Photo ID and Credit Card (Front & Back of the Card) HERE

Front Of ID Card Back Of ID Card
Front Of Credit Card Back Of Credit Card

Note: Accepted forms of identification are national, state or local government-issued forms of identification, such as a valid driverís license, passport or military ID.