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Fax-Mail Form

CleanUp Stuff Fax-Mail Form

Order Form – Fax or MailCleanupstuff.com
Print and fax to (909) 591-2350
Phone & Email Information Required to Confirm Order
Questions? Call (800)869-9633
If mailing check – Complete Ship To and products you are ordering on this form and Mail to:
PCI Product Company – 4195 Chino Hills Pkwy #360 – Chino Hills, CA 91709

Order Date______________

Purchase Order #______________

Bill To: (Credit Card Bill Address)
Name_________________________
Address_______________________
_____________________________
City/State/Zip Code______________

Phone # ( )__________________

Email_________________________

Ship To: (Mark “Same” if Bill Address)

Name____________________________
Address__________________________
_________________________________
City/State/Zip Code _________________

Item #

Name/Description

Quantity

Unit Price

Total




Sub-Total

CA Residence add 8.0% Sales Tax

Shipping (see below)

Total

Method of Payment (Check one)( )VISA® ( )MasterCard® ( )American Express® ( )Discover

Card #___________________________Exp. Date________
Card Holders Name_________________________________

Card Holders Signature______________________________

Your Comments:
Contact us at (800)869-9633 concerning shipping/exact charges before mailing.
Shipping charges are to be prepaid and will be added to your total.