Please Print Out This Form, Complete It, And Fax It To Columbia Design at 888-750-6935

Sold To: (Credit Card Address)

Name:

Day Time Phone:

Fax Number:

Last:  First:  MI

(  )

(  )

Street:

City: State: Zip:

E-mail Address:

Shipping Information (We do not ship to P.O. Boxes):

Company:

Attn:

Street:

City: State: Zip:

Qty Item Code  Description/Size  Price Each  Total ($)

Magnet Thickness(Circle): 20 mil; 30 mil Imprint Color(s): Imprint Instructions: Attach extra sheet with imprint and layout instructions, type styles, etc. Email us your logo/graphic files at sales@columbiadesign.com

Shipping Charges: Regular Ground UPS rates will be added to your order total. F.O.B. plant. Call us for current freight rates. 1-888-240-4763.

Total From Above  $  Extra Charges  $  Total Shipping  $  Sub Total (Add above lines)  $  Add 5.0% BIC State Service Chg. (CA; FL; MD; TN & WI- BIC Orders Only)  $ Add 8.25% Sales Tax (TX Residents Only)  $  TOTAL AMOUNT  $

Payment Method (Check One):

Payment Enclosed. Mail To: Columbia Design, 162 Navigator Crossing, Spring Branch, TX 78070

Charge my Credit Card

Government Purchase Order. Fax signed purchase order.

American Express

VISA

MasterCard

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Credit Card Information:

Acct. #

Exp. Date:

Signature (required for credit card orders):

Date Signed: