Medazzaland Discs Order Form
Mike Fevergeon, Owner
4217 164th St. SW #C103
Lynnwood, WA 98087
(425) 787-9203 (phone/fax)
medazz@earthlink.net

This order form is to help make it easier for those of you who want to fax or snail mail your orders in.
You should be able to print this form from the "File" menu, or save it for later use.

PERSONAL INFO

First Name______________________________

Last Name_______________________________

Address 1 _______________________________________

Address 2 _______________________________________

City ___________________ State/Province __________

Postal Code ___________________ Country ___________

e-mail address ________________________


THE GOODS

TOTAL IT UP

Total for goods $_______ + Total Shipping $_______ = Grand Total $_______

METHOD OF PAYMENT (Please check one)


___Visa

___Mastercard

Card Number_______________________________ Expires ___/___

Signature____________________________________________

___Money Order (Payable to Medazzaland Discs)