SOUTHWEST COUNTRY
ONLINE ORDER FORM
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 on your order.
Your placement of an order with us indicates your acceptance and understanding of our [
terms
] and conditions.
You will receive a confirmation of your order indicating the total including shipping and any other pertaining if any costs within 24 hours.
* Required
Email address
*
Company Name: (if any)
Purchase Order: (if any)
Full Name
*
Phone
*
Billing Address
*
Type:
Business
Residential
City
*
State/Province
*
Zip/PostalCode
*
Country
*
Item title and quantity to be purchased
*
Credit Card Information
Credit Card
*
Choose
Visa
Mastercard
Discover
American Express
Credit Card #
*
Expiration Date (mm/yyyy)
*
CCV number:
*
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:
Type:
Business
Residential
Ship to City:
Ship to State/Province:
Ship to Zip/Postal Code:
Ship to Phone:
Ship to Country: