XS-Power Fax Order Form

FAX ORDER FORM - FAX TO : 919-528-1739 - 24 HOUR FAX LINE
To order by fax print this form, fill out and fax to us.

Item Sku Number	Description	Quantity	Price Each	Total






			Sub Total
			N.C. Residents Add 6% Tax
			FREE SHIPPING with all U.S. orders
			Total

SHIPPING INFORMATION	PAYMENT/BILLING INFORMATION PLEASE FILL IN ALL AREAS
First Name_______________________________	Method of payment: Check_____ Money Order_____
Last Name_______________________________	Credit card_____________ (Visa, Mastercard, American Express, Discover)
Shipping Address _________________________	Credit Card #_____________________________
City ______________________State__________	Expiration date___/____/____ (mm/dd/yyyy)
Email Address: ________________________	CCV Number _______ (last 3 digits, back of card, signature line)
Zip Code______________	Billing Address _______________________________
Home Phone___________________	City, State, Zip _______________________________
Work Phone____________________	Cardholder’s name____________________________
Fax Number____________________	Signature____________________________________