Mail & Fax Order Form

FAX - MAIL ORDER FORM

Grizzly Cartridge Co.
P.O. Box 1466
Rainier, OR 97048
Phone: 503-556-3006
FAX: 1-503-556-8037

Bill To: Ship To:

Name:	.	Name:	.
Address:	.	Address:	.
	.		.
City, State ZIP:	.	City, State ZIP:	.
e-mail:	.	e-mail:	.
Phone:	( )	Phone:	( )

Order:

SKU #	Item Description	Manufacturer	Qty.	Price	Extended
.	.	.	.	$	$
.	.	.	.	.	.
.	.	.	.	.	.
.	.	.	.	.	.
				Shipping	TBD
				Total	$

Payment Info:

		Personal Check	Cashiers Check or Money Order

----------------------------------------------------- Card Number ---------------------------------------------------

Exp

Credit Card V-Code:

For your security, and for credit card fraud prevention, we require the V-Code on your credit card. This number is separate from your regular card number and only appears on your card. Visa, MasterCard, and Discover card holders should flip your card over. You will see your 16 digit card number followed by another 3 digits. This is your V-Code. American Express card holders will find their V-Code as 4 digits just above the card number.

_______________________________________________
Signature of Cardholder…must match "Bill To" name above.

I authorize Grizzly Cartridge Company to charge the credit card number indicated above for the total above plus sales tax and shipping (if applicable). I certify that the credit card number and signature above agree to the "Bill To" name above and that, as such, I am an authorized signer on this card.