Pemaraal FAX ORDER FORM
  ITEM DESCRIPTION (BE SPECIFIC) QUANTITY  UNIT PRICE  EXTENDED PRICE
1         
2         
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6         

LINE A
Total Price of Items Purchased _____________
LINE B
Shipping ____________
LINE C
CT Sales Tax (Connecticut Residents add 6% of Lines A & B)____________
Total of Lines A thru C______________
 
BILLING INFORMATION
Name_______________________________________ (As it appears on card.)
Card Type:
_____VISA _____MASTERCARD
____AMEX _____ DISCOVER

Card No. ____________________________________
Expiration Date ___________________
Card Verification No*. ______________
Address_____________________________________
Address_____________________________________
City_________________________________________ State/Province________________________________
Postal Code___________________
Country____________________________________  
SHIPPING INFORMATION (IF DIFFERENT)

Name______________________________________
Address____________________________________
Address____________________________________
City________________________________________
State/Province_______________________________
Postal Code__________________ Country_____________________________________
Customer Comments:
___________________________________________
___________________________________________
___________________________________________

Phone Number _____________________________
E-mail address _____________________________
    INSTRUCTIONS
  1. Please use the online shopping cart to determine prices, shipping and tax. Customers in countries not included in the shopping cart menu must email us (sales@pemaraal.com) to determine the shipping fee prior to faxing this form.
  2. Missing/Incorrect information will delay the Order process.
  3. Print and fax completed Order Form to (203) 876-0416.
*The verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number. The American Express verification number is a 4-digit number printed on the front of your card. It appears after and to the right of your card number.

CONDITIONS OF SALE
Buyer may return the undamaged or defective product within 14 days of receipt for refund of the purchase price. Other than the warranty that is provided by the manufacturer, there are no warranties which extend beyond this remedy. As a condition of sale, it is the agreement of the seller and buyer that all claims for consequential damages are hereby excluded and buyer's sole remedy for breach of warranty is limited to exchange or return of the purchase price.