Fax , Mail Order Form
Phone: 925 551 0219
Fax:   Print this form and fax it to 925 551 7963
Mail:  Send this form with your payment to:
BonusClub Co. P.O Box 2868 Dublin Ca.,94568

Product #	Item Description		Price	Qty.	Total
Please add shipping charges from the table below (US only)				Shipping
$ 0.00 TO $9.99 add $ 3.50		$ 30.00 TO 39.99    add  $ 6.90		Subtotal
$10.00 TO $19.99 add $ 4.60		$ 40.00 TO 59.99    add  $ 8.35		Tax
$20.00 TO $29.99 add $ 5.70		$ 60.00 TO 99.99    add  $ 9.00		Total
Free shipping on orders $100.00  or more ( US only)

Shipping Address

Name
Address
Address 1
City		State.
Country		Zip
Email		Phone #
Comments

Billing Address
  Check if same as shipping address

Name
Address
City		State
Country		Zip
Phone #		Fax
Email

Billing Information

Credit card
Name on Card
Card number
Expiration