Antiquities of the Prize Ring

Fax Order Form

(Print this form and fax to number listed below)

Name_________________________________

Name (as appears on the card )_________________________

Credit Card Billing Adddress__________________________

____________________________________________________

____________________________________________________

Shipping Address_____________________________________

____________________________________________________

Telephone:___________________________

e-mail:_______________________________

Credit Card Type (check one):

Visa___Mastercard___Amex___Discover___Visa Electron____

Credit Card Number_______________________________

Expiration Date________________

Verification No. ________________

Items You Wish to Purchase

Please include Item Number, Description and Price

________________________________________________________________

________________________________________________________________

________________________________________________________________

I will contact you to confirm and to quote a shipping charge

Fax to:

1.614.870.3104

PLEASE CONFIRM YOUR ORDER VIA E.MAIL antekprizering@earthlink.net

Do Not e-mail this information! This is NOT A SECURE SITE

Thank you, your business is appreciated

Harry