Printable Order Form

Please print and complete this form to help organize your order. When completed, you may:

• Call (850) 836-4121. Please have your charge card ready when you call.
• Fax this order form to us at 1-850-836-4962.
• Mail this form to: Vortex Innerspace Products, Inc., P.O. Box 168, Ponce De Leon, FL 32455

Make checks payable to Vortex Innerspace Products, Inc.

Name:________________________________________________________________
 
Address:_____________________________________________________________
 
City:_____________________State:___________________ZIP:______________
 
Daytime Telephone Number: (_______)__________________________________
 
Evening Telephone Number: (_______)__________________________________
 
E-Mail Address:______________________________________________________
 
How did you find us? ________________________________________________
 
 Item                                            Unit          Total 
 Number Quantity     Description                 Price         Price 
  
 ____________________________________________________________________
 
 ____________________________________________________________________
 
 ____________________________________________________________________
 
 ____________________________________________________________________
 
 ____________________________________________________________________
 
 ____________________________________________________________________
 
                                     Merchandise Total ______________
 
                   Florida Residents Add 7% Sales Tax ______________
 
                                Shipping and Handling  ______________
 
                                                 TOTAL ______________
For charge card orders by mail or fax:

Visa[] MasterCard[] Discover[] American Express[]
 
Charge Card Number:_______________________________________________
 
Expiration Date:__________________ CVC:_________________________

 
Signature:_______________________________________________________
 
American Express & Optima only: Card Identification Number: __________ 

The Card Identification Number is four digits printed above the embossed charge card number on American Express and Optima cards.

Shipping & Handling Charges (USA Only)

Orders up to $10.00  . . . . . . . . . $6.00
Orders from $10.01 to $20.00 . . . . . $7.11
Orders from $20.01 to $30.00 . . . . . $7.92
Orders from $30.01 to $50.00 . . . . . $8.98
Orders from $50.01 to $100.00  . .  . $10.10
Orders Over $100.00 . . . . . ... ....$11.07