With us you are protected, all your personal and credit card information is kept completely secure. We do not sell, trade or share customers information. All fields must be filled to your order. Your placement of an order with us indicates your acceptance and understanding of our [ terms ] and conditions.

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 Company Name if any:
 Purchase Order if any:
 Full Name:
Billing Address:

            Residential  Business

 State / Province:
 Zip / Postal Code:
 Item title and quantity to be purchased:
 Please write a clear description and the Item's URL/reference number from the address bar of your browser.

 Credit Card: VISA
American Express
 Credit Card #:
 Expiration Date:
 CCV Number:
Three or Four-digit number on the back of your card
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Fill the following section of the form if shipping to a different address. This shipping address must be submitted to your credit card's bank by calling the number on the back of it.

 Ship to Full Name:
 Ship to E-mail:
 Ship to address:

         Residential  Business

 Ship to City:
 Ship to State / Province:
 Ship to Zip / Postal Code:
 Ship to Phone:
 Ship to Country:

When you press the "SUBMIT ORDER" button, the computer will pause as it processes your order. Please do not hit the submit button twice. It is normal for the computer to pause while processing your order.

Your will receive confirmation of your order by E-mail, phone or snail mail. It will have all charge information made to your credit card. If you wish to pay by check or money order, you can print this form and mail it with your payment to:

Southwest Country
2238 Scenic Park St.
Thousand Oaks, CA 91362, USA
Please contact with us before sending payment so we can inform you of the shipping costs.

You can also use this form to include yourself to our mailing list.

Back to: Southwest Country Homepage

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