MAIL-IN, E-MAIL, FAX ORDER FORM
I have read, understood and I accept the Terms and Conditions and I wish to order the following items:
Please print it out. Type or print clearly. Email to: 
IMPORTANT: incompletely filled out orders will be delayed for clarification.
Code# Country Description Grade Unit Price Qty Total in €
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NOTE: Attach your order on a separate sheet if necessary. Sign every sheet.
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SUBTOTAL: ________________
POSTAGE & HANDLING (delivery by__________________________mail): ____________
Your UPS Account # (if you pay your own shipping):__________________________
Your FedEx Account # (if you pay your own shipping):__________________________
TOTAL: ________________
I am paying with/via: ( ) PAYPAL** ( ) CHECK ( ) MONEY ORDER ( ) CASH
( ) BANK WIRE TRANSFER ( ) BANK DRAFT ( ) WESTERN UNION ( ) CREDIT CARD
( ) OTHER _________________________________________________________________
** We will send you a PAYPAL invoice or provide you with our Paypal specific email address 
Your Paypal email address: ___________________________________________________
Please charge my credit/debit card 
for my order# __________:
( ) VISA ( ) MC ( ) AMEX ( ) DISCOVER ( ) NOVUS ( ) OTHER .........
Name on Credit/Debit Card: ___________________________________________________
Billing Company (if any): ____________________________________________________
Card Number*: [______________________________________________________________]
* American Express # is 15 digit, Visa 13 or 16 digit, MC & Discover 16 digit.
CVV/CVC/CIN # (3/4 digits on the back/front of your card): [_________________]
Customer Accounting Code (if corporate card): ________________________________
Card Expiration Date: [______/___________] (MM/YYYY)
Billing/Statement Address: ___________________________________________________
______________________________________________________________________________
City: ________________________________ Province/State: _______________________
Postal Code or Zip: _____________________ Country: ______________________________
DATE OF ORDER ________________________
PERSONAL/BUSINESS/SHIPPING INFORMATION (please type or print clearly)
Name: (Mr./Ms.)_______________________________________________________________
Business Name (if any): ______________________________________________________
Shipping Address: ____________________________________________________________
______________________________________________________________________________
City: _______________________________ Province/State: ________________________
Postal Code or Zip: ____________________ Country: _______________________________
( ) Check if the above address is a commercial location (for UPS or FEDEX delivery)
( ) Check if the above is a residential address (for UPS or FEDEX shipping)
( ) Check if the above address is a home-based business (for UPS or FEDEX delivery)
NOTE: please check only one selection above!
Phone number: ( )_______________________________________
Fax number: ( )_______________________________________
E-mail (print clearly): ____________________________________________________
Comments: ____________________________________________________________________
______________________________________________________________________________
Authorization Signature: _____________________________________________________
Online Order & Card Payment Form Nº006124
World Banknotes - A
