Champion Flags, Inc. - Phone 1-800-496-1776 Champion Flags, Inc. - Phone 1-800-496-1776 Champion Flags, Inc. - Phone 1-800-496-1776 ***************************************************************************** CHAMPION FLAGS / CHAMPION FLAGS / CHAMPION FLAGS / CHAMPION FLAGS ***************************************************************************** Please print, complete, and FAX this form to the following numbers: FAX Order Line: 1-800-928-3305 Toll Free PHONE Order Line: 1-800-496-1776 Official Supplier Of Top Quality Flags, Banners, Flagpoles & Patriotic Decorations ***************************************************************************** CHAMPION FLAGS / CHAMPION FLAGS / CHAMPION FLAGS / CHAMPION FLAGS ***************************************************************************** Please be aware that SALES TAX will be added to your order if it is shipped to the state of Pennsylvania. Also, a SHIPPING & HANDLING CHARGE which is listed below will be added to all applicable orders. ***************************************************************************** BILL TO Date:_________________________ ***************************************************************************** IMPORTANT: This address must match the address to which the credit/debit card is actually registered to (where the monthly statement/bill is mail to) failure to provide the proper card billing address can delay order processing. First Name: _______________________ Last Name: ____________________________ Company / Business Name: ____________________________________________________ Phone:________________ FAX:__________________ E-mail:____________________ Address(1): __________________________________________________________ Address(2): __________________________________________________________ Address(3): __________________________________________________________ City: _________________________ State: ____________ ZIP: _________________ Purchase Order #________________________ (If applicable) ***************************************************************************** SHIP TO Same As "Bill To" Address: ____ Yes ____ No ***************************************************************************** First Name: _______________________ Last Name: ____________________________ Company / Business Name: ____________________________________________________ Phone:________________ FAX:__________________ E-mail:____________________ Address(1): __________________________________________________________ Address(2): __________________________________________________________ Address(3): __________________________________________________________ City: _________________________ State: ____________ ZIP: _________________ ***************************************************************************** PAYMENT INFO ***************************************************************************** Credit Card: _____ VISA _____ MasterCard Credit Card Number:____________________________ Expiration:__________________ Name On Card: ________________________________________________ (Please print) Signature: ___________________________________________________ ***************************************************************************** SPECIAL ORDER INSTRUCTIONS / COMMENTS (If applicable) ***************************************************************************** ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ***************************************************************************** ITEM(S) ***************************************************************************** >> For assistance call: 1-800-496-1776 >> FAX Order Line: 1-800-928-3305 >> Minimum Order Amount is $20 Quantity | Item # | Description | Each | Extened Price ============================================================================== __________|________|__________________________________|________|_____________ __________|________|__________________________________|________|_____________ __________|________|__________________________________|________|_____________ __________|________|__________________________________|________|_____________ __________|________|__________________________________|________|_____________ __________|________|__________________________________|________|_____________ __________|________|__________________________________|________|_____________ Order Subtotal $ _______________ Sales Tax (Pennsylvania Customers ONLY - add 6%) $ ___________ Shipping & Handling (see chart below) $ ___________ ORDER TOTAL $ _______________ ******************************************************************** SHIPPING & HANDLING CHART ******************************************************************** ____ UPS Ground ____ USPS Priority Mail (for HI, AK, and overseas U.S. Military addresses only) Order Subtotal Shipping Charge =================================================== >> $00.01 - $50.00 | $7.95 >> $50.01 - $75.00 | $8.95 >> $75.01 - $100.00 | $11.95 >> $100.01 - $250.00 | $15.95 >> $250.01 - $500.00 | $22.95 >> $500.01 - Over | $30.95 >> FAX Order Line: 1-800-928-3305 ***************************************************************************** ***************************************************************************** *****************************************************************************