This order form is for use by those that do not want to use our secure
online ordering system.
PLEASE PRINT IT OUT, write your order in the spaces provided and fax it to
us at 1 (561) 656-1717. NOTE SHIPPING CHARGES ARE
AN ESTIMATE ONLY AND WILL BE BASED UPON ACTUAL SHIPPING CHARGES.
All orders ship via U.S. Priority Mail.
QTY.
CODE
DESCRIPTION
PRICE/EA.
TOTAL
Le Melange
LLC
Subtotal
11320
Fortune Circle Ste G15
Wellington FL 33414-8707 USA
Fla.
Residents Only - Add 6.5% Sales Tax
1
(561) 795-0202 Phone 1 (561)
656-1717 Fax
Shipping
http://www.lemelange.com
sales@lemelange.com
TOTAL
Order Total
Shipping
Name:
$00.01 - $10.00
$7.80
Address:
$10.01 - $20.00
$8.20
City/State/Zip:
$20.01 - $30.00
$10.75
Daytime
Telephone: ( )
$30.01 - $40.00
$11.75
____ Visa ____
MasterCard ____ Discover ____ AmEx ____ Diners Club
$40.01 - $50.00
$12.25
Credit Card #:
_______/_______/_______/_______
Exp. Date: _______ 3 or 4-Digit Security Code ______
(must have this to process your order!!)
$50.01 - $60.00
$15.35
Print Name As Shown On Card:
$60.01 - $120.00
12%
Signature:
$120.01 - Up
11%
Email Address:
Want your Receipt faxed as confirmation? Yes __ No __
If "Yes", Fax #: (____) ____-______
