Fax

To send your order via fax please print and fax the completed form to:

 

775-924-4436

 


Product and purchase information:

 Merchant name: Mystik Media
 Description:
 Blaze Media Pro
 Purchase amount: $50.00
 Product ID:  ______________________ (Found in bottom left corner of the Purchase window)


Billing address information:

Name:_______________________________________________________________

Street (Line 1): ________________________________________________________

Street (Line 2): ________________________________________________________

City: ________________________________________________________________

State / Province: _______________________________________________________

ZIP / Post Code: _______________________________________________________

Country: _____________________________________________________________

Phone: ______________________________________________________________

E-mail: ______________________________________________________________


Credit Card Information:

Only credit card orders can be received via fax. Please supply the below information:

Card Type: ____________________________________________________________

Card Number: _________________________________________________________

Expiration Date: ________________________________________________________

Signature: _____________________________________________________________

 

Thank You For Your Order!