Printable Order Form:
To submit an order, please print this form and mail to:
MOLLOY
6724 Perimeter Loop Rd.
Suite 185
Dublin, OH 43017
Or Fax to:
Please allow 7 to 14 days for shipping.
Items Ordered:
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Item Number
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Item Title
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Size
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Color
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Quantity
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Price
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e.g. 001
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e.g. Digital Cable Filter
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e.g. N/A
|
e.g. N/A
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e.g. 1
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e.g. $24.95
|
|
002
|
Digital Cable Filter
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|
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2
|
$46.95
|
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003
|
Digital Cable Filter
|
|
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3
|
$57.95
|
|
004
|
Digital Cable Filter
|
|
|
4
|
$68.95
|
|
005
|
Digital Cable Filter
|
|
|
5
|
$76.95
|
|
|
|
|
|
|
|
|
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Plus $7Per Item for Shipping & Handling
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|
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Plus an additional $12 to have items shipped by Priority Mail
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Total
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For more items, please print and include a second form.
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Customer Information
*First Name ________________________
*Last Name ________________________
Company ________________________
*Email ________________________
Phone _________________________
Credit Card Information
*Card Type ________________________
*Cardholder’s Name As Shown On Card ___________________________________
*Card Number ______________________
*Expiration Date (mmyy) ____ / ____
*3 Digit Security Code _______________
*Required fields.
|
Billing Address
*Address Line 1 ______________________
*City _______________________________
*State/Province _______________________
*Country _____________________________
*Zip/Postal Code ______________________
Shipping Address (if different from billing address)
Ship To Name __________________________
Address Line 1 __________________________
City __________________________________
State/Province __________________________
Country _______________________________
Zip/Postal Code _________________________
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Thank you for ordering from Dtvfilter. If you have any questions, please do not hesitate to contact us by email at: orders@dtvfilter.com.
