Sunny Shack Sungalsses ShackFax

Sunny Shack^® Sunglasses Fax Order Form

Ordering Your Sunglasses via Fax is as easy as 1., 2., 3... You can use this form to order your sunglasses via fax. Please print this form and fill it out completely. Make sure you sign and date the form, and include your credit card number. Once you have completed all of the above, fax the order to 1-888-SHACK-FAX (1-888-742-2532). Note: your order cannot be processed until we receive your signed order confirmation form via fax.
1. Please provide the following billing/shipping information (for credit card security reasons, sunglasses can only be shipped to the billing address of the credit card).

First Name_____________________ Mid. Initial ___	Last Name __________________________
Street address _______________________	Suite/Apt./No. _____________
City ______________________	State/Province______________
Zip_______________________	FAX (optional) ____ -- _____-- _______
Home Phone ____ -- _____-- _______	Work Phone ____ -- _____-- _______
E-mail _______________________________
___Yes, please send me special offers from Aardvark Sunglasses via email	___No, please do not send me special offers via email

2. Please provide the following ordering information:

QTY	Model(ex DR5460)	DESCRIPTION (ex Pandemonium Silver/Silver mirror)

Shipping Charges 1/$6.50 2/$7.75 3/$9.50 US Addresses Only
Texas Sales Tax 8.25% for all shipments to Texas addresses

3. Please Provide the following payment information:
Promotional Code ____________________ (optional)

Total Charges due: $________________ Please Include Shipping and Applicable Taxes

Payment type (Circle One): Discover, Visa, MasterCard, AMEX

Cardholder name ______________________________________

Card number ________--__________--__________--__________

Expiration date (ex. 03/99) ____________

Issuing Bank    (ex. Citibank, MBNA, etc.) ______________________________________

Credit card 800 Number ______________________________________
(bank information is used for fraud prevention checks)

I agree to pay for the above goods and services. I have read and agree to the terms and conditions regarding shipping and 30-day return policy . Note: the charges for this purchase will appear as "Powertosee.com" on your credit card statement.

_______________________________________________        _______________
Cardholder                                                                                  Date