InspiredLiving.com Order Form for Fax or Mail Orders

Fax / Mail Order Form Mail to InspiredLiving.com, PO Box 388, Dundee OR 97115 or fax to 503-554-0840 Money Orders, Cashier's Checks and Preprinted USA Checks ONLY payable to InspiredLiving.com.
Customer Shipping Information
Company		First Name
Ship Address		Middle Initial
Ship Address		Last Name
City		Phone (required)
State		Email Address
Zipcode		Date Ordered
Special Instructions

Order Information
Qty	Description of Products	Unit $	Total $
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Call 866-875-4386 for shipping charges		Shipping	_______
We accept credit cards, preprinted checks, money orders, cashier's checks		Amount Due	_______
Payment Information
Payment: (circle one): Visa · MasterCard · Discover · American Express · Check · Money Order _______________________________________ Credit Card # ___ / ___ Expiration Date (mm/yy) _____ 3 Digit Verification Code (on the back of the card, in the signature field, it's the last 3 digits on the right) _______________________________________________________ Name on Card (if different from above) _______________________________________________________ Billing Address (if different from shipping) Please send me the selected products. I understand there is a charge for returned checks and unauthorized credit card charge backs. I authorize InspiredLiving.com and its agents, including financial institutions, to initiate debit entries for the products ordered plus shipping where applicable. _____________________________________________________ Signature