Prepaid Mail-In or Credit Card FAX Order Form

Prepaid Mail-In and Credit Card FAX Form

1. Please Print and Complete This Order Form.

2. List Items You Wish to Order and Quantities Desired.

3. FAX This Form with Your Credit Card Information to: (908) 226-8715

...or Mail this Form with Your Check, Money Order or Credit Card Information ... to the address listed below:

USCCCN INTERNATIONAL, INCORPORATED/AMERICAN FOCUS
Post Office Box 663
South Plainfield, New Jersey 07080-0663
Fed. ID# 22-3248936

PRINT Name:_________________________________________________________________________________

Firm/Org/Agency/Inst:_________________________________________________________________________

Address:_____________________________________________________________________________________

City:____________________________________ State:___________________ Zip:________________________

Telephone: (_________) _______________________________ E-Mail:__________________________________

QUANTITY................ITEM...........................................................SUBTOTAL...............TOTAL

_______ __________________________________________________ $________________ $_________________

_______ __________________________________________________ $________________ $_________________

_______ __________________________________________________ $________________ $_________________

_______ __________________________________________________ $________________ $_________________

_______ __________________________________________________ $________________ $_________________

_______ __________________________________________________ $________________ $_________________

Shipping via USPS Priority Mail or Best Way. Subtotal of Order:$________________________

**CHECKS/MONEY ORDERS Must Be Made Payable To: USCCCN INT'L, INC./AMERICAN FOCUS):

NJ(Only) Purchasers Must Add 6% NJ Sales Tax: $________________ Exempt#:______________________

Total Including Sales Tax (NJ Only):$____________________________

Total of Check/Money Order Enclosed:$___________________________

****CREDIT CARD ORDERS:

Sub-Total of Ordered Items:$_______________________________

NJ (Only) Purchasers Must Add 6% NJS Tax $________________ Exempt#__________________________

Total Including Tax (NJ Only):$__________________________

Credit Card: ___Visa __Master Card __AMEX __Discover ....................Expiration Date:________/_______

Credit Card Number:____________________________________________________________________________

Name on Card:_________________________________________________________________________________

Signature:_____________________________________________________________________________________