back Middlepeg Order Form
| Please print the following form. For prompt and efficient delivery please ensure all details are correct. Fax it to us at: (08) 9410 2491 (local) or +61 8 9410 2491 (international) or Mail it to us at: Middlepeg Orders PO Box 1010 Bibra Lake 6965 Western Australia |
| Customer Name
_____________________________________ Date
_____________
Delivery Address _________________________________________________________ _____________________________________________ Postcode/ZIP _____________ Home Phone ______________ Work Phone _____________ Mobile _______________ Fax _______________ Email ________________________________________ |
| Middlepeg Code |
Item & Description |
Quantity | Price (per unit) |
Total |
|---|---|---|---|---|
|
* Plus Postage + ________ TOTAL (AUS $) = ________ Payment Details Cheque** Money Order Visa Card Mastercard Bankcard Credit Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Cardholders Name (as shown on card) _________________________________________ Expiry Date _____________ Cardholders Signature ________________________ * Overseas orders please
contact us for the most suitable postage option.
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