IMEX MARKETING CO. INC. Fax / Mail Order From


	MAIL/FAX ORDER FORM
	1611 W. Commonwealth Ave. Fullerton, CA 92833 Phone: 714-525-0505 / Fax: 714-525-0319

Please print out this order form and fax it to our order center for processing. Thank you.

A1. ORDER INFORMATION

A2. DIET SLIPPER ORDER FORM

MALE / FEMALE

SOLID COLOR
(BLACK / RED / BROWN / BLUE)

FLOWER
DESIGN

SIZE

QTY

UNIT PRICE

EXT. PRICE

SUBTOTAL

Sales Tax (7.75%)

CA Resident Only

Shipping Charge

TOTAL

B. SHIPPING & BILLING INFORMATION

BILL TO:

NAME: ________________________________________________________

E-MAIL ADDRESS: _______________________________________________

ADDRESS: _____________________________________________________

CITY: ___________________________ STATE _______ ZIP CODE ________

COUNTRY: ____________________________________

DAY TIME PHONE: _____________________________

EVENING PHONE: ______________________________

FAX NUMBER: _________________________________

SHIP TO:

NAME: __________________________________________________________

ADDRESS: ______________________________________________________

CITY: ___________________________ STATE _______ ZIP CODE ________

COUNTRY: ____________________________________

C. PAYMENT INFORMATION

MONEY ORDER IS INCLUDED;

CREDIT CARD TYPE:

VISA MASTER CARD AMERICAN EXPRESS

CARD NUMBER: ________________________________________________

EXPIRATION DATE: _______ / ________

NAME OF CARDHOLDER: _________________________________________

CREDIT CARD BILLING ADDRESS: __________________________________

CITY: __________________________ STATE: ______ ZIP CODE: __________

Resellers in State of California are required to send in a copy of reseller permit.