Brackenís Jewelers - Fax Order Form - 1-310-821-6052

Thank you for your interest in our beautiful jewelry.
To purchase an item using this Fax Authorization Form:
(1) Simply, print this page.
(2) Complete the information requested below and fax it back to Brackenís Jewelers.

(see our "Ordering Information" page for TERMS AND CONDITIONS)

Direct any questions to your salesperson. Salesperson.: ______________________________
Customer Information
Name: (Please Print) __________________________________________________________

Tel: ( ____ ) ______________ Fax: ( ____ ) ________________Email: ________________
Shipping Address:
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Item Name :__________________________________________________________________________

Size: _______________ Price: ______________________

Shipping Charges & Specifications: ____________________(see "Ordering Information" page for details)

Sales Tax (8.25% CA residents only):__________________

Total Amount to be charged: $ _____________________

Brackenís Jewelers has my written permission to charge my credit card for the above listed
merchandise in the above listed total amount.
 

Credit Card Number: ______________________________________________________

Expiration Date: _________________ Card Type: ______________________________
Credit Card Billing Address:
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Signature: _______________________________________________________________