BRIWAX - order Form

Please provide the following contact information:

Name
Business
Street Address
Address (cont.)
City
State
Zip/Postal Code
Home Phone
FAX (Optional)
E-mail

In order to provide you with the the total cost including shipping and not overcharge you like so many companies do we request that you fill out the information below and we will email the order back to you including shipping and tax if appropriate. You can then review the order, shipping charges, and total cost and provide your credit card information to our secured site.

Thank you for your order. We will ship as soon as the transaction is complete.

Include the item you want to purchase, and the quantity, and the color for Briwax.

QTY	DESCRIPTION

	BILLING
Purchase Order #
Account Name

	SHIPPING (If different from above)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country