Essential Orientals Fax Order Form
				
If you do not wish to send your Credit Card information via the Web
please print this page and fill in the information.
Then sign it and fax it to 1 866 763-0378 toll free.

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Product Description 		Price		Quantity		Total
(eg. SHAWL - fire engine red)	(eg. $95.00)	(eg. 1,2,3)	(eg. $95.00)

_______________________________	____________	___________	____________
			
_______________________________	____________	___________	____________

_______________________________	____________	___________	____________

_______________________________	____________	___________	____________

_______________________________	____________	___________	____________
			
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SHOPPER INFORMATION                   	  SHIPPING INFORMATION
			  		 same as Shopper?   (yes/no) _______

Name	___________________________	Name	________________________________

Address	___________________________	Address	________________________________

Address	___________________________	Address	________________________________

City	___________________________	City	________________________________

Prov/State   ___________			Prov/State	____________

Postal Code  ___________			Postal Code	____________

Country	     ___________			Country		____________
		
Telephone    _____________________		Telephone	_______________________

Fax	     _____________________		Fax		_______________________

Email	     _____________________		Email		_______________________


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Credit Card Information	

Card Type   (Visa, Mastercard):	_______________________________

Number: __________________________________	

Expiration (mm/yy):______	


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When you have completed entering your information, please: 

1) PRINT THIS PAGE and SIGN IT HERE __________________________________________ 
                                      to authorize your credit card purchase. 
2) FAX the printed pages to 1 866 763-0378 toll free.