8872 La Mesa Blvd, La Mesa, CA 91941
PHONE  619 461 4440
 email: info@fusionglassco.com
PRINT ORDER FORM AND FAX TO 619.461.1770
                               FIRST                                       LAST
    IF DIFFERENT FROM BILLING ADDRESS
Name: Ship To:
Attn: Attn:
Address: Address:
City: State: Zip: City:
Daytime Phone: State: Zip:
   
FAX: 619.461.1770
E-Mail:
Quantity
Description
Unit Cost
Total Price
       
       
       
       
       
       
       
       
       
       
       
Payment
_____ MC    
_____ VISA    
_____ MONEY ORDER    
_____ CHECK
Charge# __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Exp. Date: __ __ - __ __        Secret Code __ __ __ (three digits on back of card )
PRINT Card Holder's Name: __________________________________
Signature: ________________________________ Date: __________________
Sub-Total
  
Shipping
(Mulitply by 10%)
 
 
7.75% CA tax
(if applicable)
 
TOTAL
  
 © FusionGlass Company 2007
619 461 4440   |    8872 La Mesa Blvd, La Mesa, CA 91941   |  info@fusionglassco.com