The Museum of Lead Mining

Fax/Post Order Form

 Fax - Post Order Form

Please print out this form, complete all information below and fax or post it to us. It is important that you include your phone and fax numbers in case we have to contact you regarding your order.

Date

Shipping Address:

  

Billing Address: (For Credit Card)
Name   Name  
Address   Address  
Address   Address  
City   City  
State/County   State/County  
Postal/Zip Code   Postal/Zip Code  
Tel No   Tel No  
Fax No   Fax No  
Email   Email  

ORDER

Quantity Description Colour/Size Unit Price Total
         
         
         
         
         
Sub-Total:

 
Shipping:  
Total:  

 

CREDIT CARD DETAILS

Please circle card type:

Visa - Access - Mastercard
Card Number:  
Expiry Date:  
Signature  

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