Discount Printer Ink Cartridges .com -- Order Form

10200 SW Eastridge St, Ste #105, Portland, OR 97225 - phone +1 503 972 0360 - fax +1 503 643 5379 - support@discountprinterinkcartridges.com

After filling out this form
Please fax it to +1 503 643 5379
or mail it to us at:

10200 SW Eastridge St, Ste #105, Portland, OR 97225

For Office Use Only
     Order #:
     Date received:
     By whom:

Name:
Company:
Shipping Address:
     [   ] Return for exchange
     [   ] Return for refund
     [   ] Return for in-store credit
     [   ] Return for repair/replacement
     [   ] Advanced replacement/return

Contact Name:
     Email:
     Telephone:
     Fax:

	Part Number	Qty	Price per Item	Subtotal
Line 1
	Description:
Line 2
	Description:
Line 3
	Description:
Line 4
	Description:
Subtotal:
Shipping (UPS or USPS):
Handling ($5.00 for all international orders):
Order Total:

Cardholder Name:
Billing Address:

Credit Card#:
Expiration Date:
CVV # (found on the back of credit card):

Purchase Order # (if applicable):

I am the authorized account holder of the credit card listed above.

I have read, understood and agree to be bound by the Terms and Conditions of Sale (see http://www.discountprinterinkcartridges.com/terms.htm [link]) and the Return Policy currently in effect (see http://www.discountprinterinkcartridges.com/return_policy.htm [link]).

Your order form must be signed and faxed to +1 503 643 5379 or mailed to the address above and we will process it. A response will be emailed to you. It is the responsibility of the customer to ensure receipt of this form by Discount Printer Ink Cartridges .com.

Signed:_________________________________________________ Date:_______________________