9330 Thornwood Drive Lincoln NE 68512 Fax
402-464-2070 Phone (800) 872 - 8864
E-mail = info@wikcoind.com Please Fax, e-Mail, or Mail This Order Form
Order Form FIRST
NAME: ________________________________ LAST
NAME: ________________________________ COMPANY
NAME: ________________________________ SHIPPING
ADDRESS: ________________________________ CITY:
________________________________ STATE:________________________________
ZIP:
________________________________ PHONE:
________________________________
If
paying by check or money order, please enclose payment with your order.
If paying by credit card, please include the credit card number below,
along with a signature in the signature box. [ visa,master card,discover,american express]
TYPE OF CREDIT CARD:________________________________
CREDIT CARD NUMBER: ________________________________
EXPIRATION DATE: ___________________ Security Code:_____________________
SIGNATURE:_________________________________________________
Please fill out the mailing address if it is different from your
shipping address, and/or if the shipping address is different from the
billing address on the credit card you are using. When you fax or mail
the order form, please sign this sheet in the appropriate box below
when paying by credit card.
Please note: by signing this order form you are agreeing that your
credit card billing address is either the same as the shipping address,
or is the mailing address listed below. This authorizes Wikco
Industries to ship your order to the shipping address listed on this
form.
MAILING ADDRESS:________________________________
CITY: ________________________________
STATE: ________________________________
ZIP CODE: ________________________________
