Order Form Flyer

COMPLETE FORM AND FAX TO: 928-764-1481 Close Window

CUSTOMER INFORMATION:
PLEASE FILL IN ALL BOXES BELOW THAT PERTAIN TO YOUR NEEDS

Agents

First Name Last Name

Company Name

office Address:

City:

State:

Zip Code:

office Phone:

Cell /2nd Ph:

Agents Email

Contact Name If
Different Tan Above:

Phone
Number:

BILLING INFORMATION:

Credit Card Type (Please Check One)

Master Card:

Visa Card:

American Express:

Card Number:

Expiration Date:

Month

Year

CVCC #

3 / 4Digit Code On Back / Front Of Card

Card Holders Name

First Name Last Name M.I.

Billing Address:

City:

State

Zip:

Agents Signature For Ordering Authorization:__________________________________________________

Listing Information and Product Selection:

MLS Number:

Property Address:

City:

State:

Zip Code:

Product Selection:

Put a Check in Box or Boxes That Applies To Your Needs

8.5" x 11Flyer Paper Select Paper Recap Your Order
	1 Sided 24 LB. Paper (B & W)	Amount of Package Choice	$
	2 Sided 44 LB Gloss White Brochure	Additional Color Prints X 65¢ # ( )	$
	Package (A) 30 Color/100 B&W - $87.95	Additional (B W) Prints X 05¢ # ( )	$
	Package (B) 50 Color/200 B&W - $99.95	Delivery $7.95 X ( ) Locations	$
	Package (C) 100 Color/300 B&W - $129.95
	Additional Color Flyers - $.65 ea	Sub Total	$
	Additional B&W Flyers - $.05 ea	Sales Tax Arizona Only 7.85%	$
	Delivery $7.95 & up (Local Free)	Total Amount Due	$
* Script - 12 Lines, 40 Character Ea. or 375 Character Paragraph Please Fax Your Script on a Separate Sheet With Your Signature

If You Have Any Question Please Contact Customer Service at 928-486-4848
Email: support@web360pix.com Email Orders to: order@web360pix.com