Fax/Mail Purchase Form
Print this form to purchase with your Visa, MasterCard, via fax or mail.
(To print using Internet Explorer, choose File | Print.)
Fax Order to: 562-867-8317
or Mail Check or Money Order to:
MizzEviee’s Biker Threads
17643 Virginia Ave
Bellflower, Ca 90706, USA
ITEM NAME/DESCRIPTION _____________________________________________
COLOR______________________________SIZE____________________________
QUANTITY_____________
Credit Card Information: Mastercard ( ) Visa ( )
Name on Credit Card _____________________________________________
Credit Card Number ___________-___________-___________-___________
Expiration Date _________/__________(MM/YYYY)
Billing Address:
Street __________________________________________________
City _____________________State/Province _________
Zip/Postal Code __________ PHONE:_______________________________________
Email address__________________________________________________________
(We will send your receipt and and request for confirmation to the email address that you give us.
Shipping Address if different than Billing Address.
Street_________________________________________________________________
City___________________________State/Province____________________________
ZipCode_______________________PHONE__________________________________
Special Instructions:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________