Chinrose International
6760 SW Hergert Road, Cornelius, OR 97113 U.S.A.
P.O. Box 548, Cornelius, OR 97113 U.S.A.
Phone: (503)357-7553 (888)887-7553 Fax: (503)357-5522
www.chinrose.com
ATTENTION:__________________________________________________________________
Order Date:_________________________
Company Name:________________________________________________________________
I hereby authorize Chinrose International to charge my credit card as follows:
VISA MASTER CARD
In the Amount of $_________________________________ plus shipping charges, for the purchase of Padlocks/Safes/Hardware.
QTY:_____________ITEM NUMBER(s):___________________________________________
DESCRIPTION:________________________________________________________________
CARD #:______________________________________________________________________
CARD HOLDERS NAME:_______________________________________________________
EXPIRATION DATE:______________3- DIGIT CODE (on back of card):_________________
BILLING ADDRESS FOR CARD: SHIPPING ADDRESS:
____________________________________ ____________________________________
____________________________________ ____________________________________
____________________________________ ____________________________________
SIGNATURE OF CARD HOLDER:________________________________________________
DATE:_____________