lowthertitle.gif (2723 bytes)

Print this form and mail to:
1001 Harlem Ave., Forest Park, Illinois, 60130
or FAX to 708-848-4971

Order Form
Date:
Name:
Shipping Address:
City, State, ZIP
Phone: (home) (work)
FAX: email:
ITEM(s) Ordered:  Quantity: Unit $ Total $
1.                                                                                               
2.                                                                                               
3.                                                                                               
4                                                                                                 
5.                                                                                               
6.                                                                                               
Shipping charge (where applicable)                              
Total Purchase:                             

Credit Card Authorization
Name (as it appears on card):                                                    If different than the shipping address we will need your credit card billing address: 

 
Card Number:                                               Exp Date:             
 
Your Signature:                                                                                                      Date:                    
 

You may send us this order by regular mail, or by fax. We will accept phone orders as well, but due to the large amounts potentially charged, we still need a copy of this order form.  Thank You!   --Lowther America