Interlakes Distribution Ltd. Order Form

PLEASE NOTE: IF YOU CHOSE TO PAY USING CHEQUE OR MONEY ORDER, THEN NO GOODS WILL BE SHIPPED UNTILL PAYMENT HAS BEEN RECEIVED IN FULL. ANY REQUEST BEARING FAULTY CREDIT CARD INFORMATION WILL BE DISCARDED IMEDIATELY.

DATE: -- dd/mm/yy

PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION:

 
First name
Last name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
 
IF DIFFERENT FROM ABOVE, SHIP TO:
 
First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
 
SHIP VIA:

OTHER INFORMATION:

PLEASE PROVIDE A LIST OF THE GOODS THAT YOU WOULD LIKE TO PURCHASE:
 
CATALOGUE NO. QTY DESCRIPTION
 
CHOOSE ONE OF THE FOLLOWING PAYMENT OPTIONS:
CHEQUE OR MONEY ORDER
BANK DRAFT TRANSFER
VISA
MASTERCARD

CARD NUMBER:

EXPIRY DATE: -- dd/mm/yy

COMPLETE NAME ON CARD: