Printable order form for FAX orders.
Print this page, and fill out the form completely, and be sure to fill in all required fields. Required fields noted with an *.
Your first and last name must be listed as it appears on your credit card.
(1-877-333-2447)
*First Name:
*Last Name:
*Ship to address line 1:
*Ship to address line 2:
*Ship to city:
*Ship to state:
*Ship to zip:
Billing address (as it appears on your credit card statement), if different from Ship to address.
*Bill to address line 1:
*Bill to address line 2:
*Bill to city:
*Bill to state:
*Bill to zip:
*Home phone number:
Email:
*Credit card number:
*Expiration date:
*3 digit security code on back:
(Last 3 digits of number imprinted in signature box on back of your card)
*Cigarette Brand
*Style
*Quantity
(King's, 100's, 120's, & Box or Soft)
(Marlboro, Winston Lights, Newport)
(1, 2, 3, 4, 5)
Special Instructions or comments:
