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Gifts & Collectibles: Product Order Form
Customer E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address.
E-Mail:*
Item Catalog Number, Price & Quantity
AGC Catalog Item 1:*
Qty
2
3
4
5
6
7
8
9
10
AGC Catalog Item 2:
Qty
2
3
4
5
6
7
8
9
10
AGC Catalog Item 3:
Qty
2
3
4
5
6
7
8
9
10
AGC Catalog Item 4:
Qty
2
3
4
5
6
7
8
9
10
AGC Catalog Item 5:
Qty
2
3
4
5
6
7
8
9
10
AGC Catalog Item 6:
Qty
2
3
4
5
6
7
8
9
10
AGC Catalog Item 7:
Qty
2
3
4
5
6
7
8
9
10
Sub-Total:
Shipping & Handling:
Choose Shipping
Standard Shipping 1 Item $6.50
Standard Shipping 2 - 5 Items $8.50
Standard Shipping 6 - 10 Items $12.50
Overnight Shipping 1 Item $15.50
Overnight Shipping 2 - 5 Items $21.50
Overnight Shipping 6 - 10 Items $27.50
Grand Total:
Billing Information
First Name:*
Same name as on your card
Middle Initial:
Last Name:*
Address Line 1:*
Where your statement is mailed
Address Line 2:
Apt. or Suite No.
City:*
State:*
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:*
Phone:
Shipping Information
Same As Billing Info
First Name:
Middle Initial:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Credit/Debit Card Information
Card Brand:
Choose a Card
American Express
Discover
Master Card
Visa
Card Number:*
No dashes or spaces please
Expiration Month:*
Month
January
February
March
April
May
June
July
August
September
October
November
December
From your card
Expiration Year:*
Year
2004
2005
2006
2007
2008
2009
2010
2011
From your card
Card Brand:*
Choose a Card
American Express
Discover
Master Card
Visa
CVV2:*
Card Security Code
Checking Account Information
Routing Number
If-Paying-by-Check
Account Number
Driver`s License Number*
State:*
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
MR # (Supplied by local merchant, IF APPLICABLE)
MR # (if any)
(Info added by merchant.)
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