Mirror Place Online Order Form

FAX, MAIL or EMAIL ORDER FORM

1. Please Enter the Customer Billing Information (As it appears on your Credit Card):

Email Address:

Name:

Address:

Address line 2:

City:

State or Providence:

Zip or Postal Code:

Country:

Phone:

Fax:

2. Please Enter Ship To Address: (if different from above)

Use the same billing address as the shipping address.

Name:

Address:

Address line 2:

City:

State or Providence

Zip or Postal Code

Country:

Phone:

3. Please Fill in Your Order. (Prices listed on the Online Store.)

Item#	Product Description	Price Ea	Qty	Total




		SubTotal
Sales Tax will be added to your order if applicable (NY Residents Only)		Sales Tax
Choose Shipping:		Shipping
	(See Order Info Page for shipping costs)	Total

4. Payment Method:

Mailing with Check payable to Practical Solutions, 233 Fillmore Ave., Suite 23, Tonawanda, NY 14150

American Express

Visa

Master Card

Discover Card

Card Number

Exp. Date

Signature:

________________________________________ (Must be signed if faxed).

Message or Comments: (If faxing this form you may need to put your comments on a separate page)

Please fax or mail your order.

Thank You for Shopping with us!