Zeropa Order Form

ORDER FORM

To place a secure online order with your credit card, click on the "ORDER" buttons below. This will take you to the order page for the item you selected. After making a selection or viewing your cart, you may modify quantities, continue shopping or checkout. Your billing and shipping information will be collected at checkout.

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First & Last Name:	_________________________________________________
Company Name:	_________________________________________________
Street Address:	_________________________________________________
City, State & ZIP:	_________________________________________________
Daytime Phone:	_________________________________________________


Quantity	Price
for cell phones
_____Red _____Gold _____Silver	x $49.95 = ____________
To order online click here: VIRGINIA RESIDENTS CLICK HERE: (Price will include Sales Tax)
ZEROPA PLUS for Televisions and Computers
_____Hot Pink _____Gold	x $99.95 = ____________
To order online click here: VIRGINIA RESIDENTS CLICK HERE: (Price will include Sales Tax)


To order online click here: VIRGINIA RESIDENTS CLICK HERE: (Price will include Sales Tax)

Sub Total	$ __________________
Zeropa -$3 Zeropa Plus -$5 Additional items $2 per item Shipping & Handling	$ __________________
Virginia residents, add 5% sales tax. Sales Tax	$ __________________
Total enclosed or to be charged:	$ __________________

PAYMENT
Method: VISA ____ M/C ____ AMEX ____ Discover ____
Card Number: _______________________________	Expiration: ________
Signature: ______________________________________________________

THANK YOU FOR YOUR ORDER!

ALL ORDERS WILL BE SENT OUT WITHIN 7-10 BUSINESS DAYS.
SHOULD THERE BE A BACKORDER, WE WILL CONTACT YOU IMMEDIATELY.