Fax/Mail Order Form

Print this page, fill it out completely and fax to 847-918-9438 or mail to:

CatalogClearance.com
Shop Online, Inc.
803 East Orchard Street
Mundelein, Illinois 60060

Please include either a check made payable to Shop Online, Inc or your credit card information.

Item #

Description

Price

Qty

Total

         
         
         
         

Sales Tax 7.0%
Illinois Res. Only

 

Shipping & Handling

 

Total

 

 

Keycode: ________________

Personal Information

Name: ___________________________________

Address: _________________________________

City:_____________________________________

State:__________________

Zip: __________________

This address is: __ Residential   __ Commercial

Phone Number: (_____) _____________________

Email Address: ____________________________________

Payment Method

(please check one)

___ Visa   ___ MasterCard

___ Discover   ___ Check

Expiration Date: ______________

Account # __________________________________

CVV # ___________

How would you like to be contacted?

__ Phone   __ Email