Mail Order Form

Printable Mail Order Form

Customer Data Sheet
To conserve ink, you may want to print this form in greyscale!!!
Name:
Email:
Street:
City:
State:
ZIP:
Phone:

Ordering Information

Note: You can type in as many words as you like in the "Item Description"
box...

Item # & Style

Quantity

Price Per Item

Total Price

Shipping:

Sub Total:

Sales Tax: (WA residents only)
Please add 8.2%

TOTAL:

Shipping Options:

US and Canada - $5.99

International Orders - $11.99

For more shipping options and information CLICK HERE

Credit Card Payments

Type of card			Visa Discover Master Card American Express
Name on card
Card number
Expiration date
Click here to "sign" the Credit Card Voucher

To pay by check or money order,
please mail this printable form
to:
MAXIMUMEYEWEAR.COM
826 North Ash
Ponca City, OK
74601

Questions? Send Us A Message:

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