Sunny Shack Sunglasses Mail Order Form

Sunny Shack^® Sunglasses Mail Order Form

Ordering Your Sunglasses via Mail 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, mail the order to Please Make all Money Orders and Checks to PowComm:

106 N. Denton Tap Rd.
Suite 210-284
Coppell, TX 75019

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 ______________________________________ Middle Initial __________

Last Name ______________________________________

Street address ____________________________________

Address (cont.) ___________________________________

City ___________________________State/Province ____________

Zip/Postal code ___________________

Work Phone (ex xxx-xxx-xxxx) ____ -- _____-- _______

Home Phone (ex xxx-xxx-xxxx) ____ -- _____-- _______

FAX (optional)   ____ -- _____-- _______

E-mail __________________________________________________

___Yes, Please send me special offers from Aardvark Sunglasses via email

___No Thank you, 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

Promotional Code ____________________

Total Charges due: $________________ Please Include Shipping and Applicable Taxes
Note: if your total is different from the actual amount due, we will notify you via email before processing the order.

3. Please Provide the following payment information:

Payment type        _______________________ (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

Sunny Shack® Sunglasses Mail Order Form

Sunny Shack^® Sunglasses Mail Order Form