PoliceSpecial.com
Customer Fax Orders
Instructions: To place your order by fax, print this form, then fill out the appropriate information below. Be sure to include a complete description of each item including all options such as finish, weapon fit, color,  etc. Also complete the “Ship To” and “Bill To” sections including your credit card payment information.
Fax orders are to be submitted to
866.809.5551
Note: Fields that are in bold are required.                       Order Date:
 
Bill To Information
MUST BE CREDIT CARD MAILING ADDRESS
Ship To Information
NOT CREDIT CARD ADDRESS
   - First Name:
 
   - First Name:
 
   - Last Name:
 
   - Last Name:
 
   - Email Address:
 
   - Email Address:
 
   - Agency:
 
   - Agency:
 
   - Address:
 
   - Address:
 
   - City:
 
   - City:
 
   - State:
 
   - State:
 
   - Zip Code:
 
   - Zip Code:
 
   - Phone Number:
 
   - Phone Number:
 
   - Fax Number:
 
   - Fax Number:
 
Credit Card
   - Credit Card Circle One:      MASTER CARD  /   VISA  / AMERICAN EXPRESS  /  DISCOVER
   - Name on Credit Card:
   - Credit Card Number:
   - Billing Zip Code:
   - V-Code on back of card:
   - Credit Card Expires:
  
   -Signature of card holder:

 
Order Detail
  QUANTITY    /    ITEM NAME    /    PRICE
OPTIONS (COLOR, FINISH, SIZE, GUN FIT, RIGHT/LEFT HANDED, ETC.)
1
 

 

 
2
 

 

 
3
 

 

 
4
 

 

 
5
 

 

 
6
 

 

 
When Completed, Fax To 866.809.5551

 

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