FASTPIXS.com

FAX TO: Fastpixs 519-271-1345

MAIL TO: Fastpixs Digital Media 46 Portia Blvd., Stratford, ON N5A 4V5

PHONE: 519-271-1345

1. Print this form 2. Fill out all that applies 3. FAX or Mail it to Fastpixs Digital Media

DATE:

BILL TO:	SHIP TO: *if different then bill address
Name:	Name:
Address:	Address:
City:	City:
Province /State:	Province /State:
PC/ Zip:	PC/ Zip:
Phone: (___ )	Phone: (___)
Email:	Email:

PAYMENT INORMATION:

Card Number:__________________________

Exp. Date: ____/____

Security Code:__________ (FOUND ON BACK)

Signature:_____________________________

Photo Image #:	Colour/ Make	Size:	Qty:	Price:	Total:

SUBTOTAL: (Corresponding Shipping Costs will be applied to your end charge)

Special Instructions:

Order shipment is subject to verification & approval of corresponding form. You will be contacted upon receipt of your order form.