Please print this order form and fax it to 520-577-1456, or
mail to Canyon Country Originals, LLC, 6030 East Fangio Place, Tucson, AZ 85750.


Date: ___________________

Name: ______________________________________________________

Telephone Number: (please *mark* the number where you prefer to be contacted)
Evening ______________________________ Daytime ______________________________
Email: ______________________________________

Address on Credit Card: _______________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Address for Shipping : _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Items Ordered: Item #_______________ $_______________  
  Description____________________    
  Item #_______________ $_______________  
  Description____________________    
  Subtotal $_______________  
  (Subtract 5% for payment by check or MO) ($______________)  
  AZ residents add 6.1% sales tax $_______________  
  Packing/Shipping @ $15/pkg* $_______________  
  Total in U.S. Dollars $_______________  

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Credit Card Number: __________________________________________________________
Expiration Date: ______________________
Your name as it reads on your credit card: _________________________________________
V-Code on VISA and MasterCard, C-ID on AmEx: _________________ (V-Code is three numbers in the signature block, following last four digits of VISA & MasterCard numbers. C-ID is four numbers printed on front of AmEx card, above and to the right of card numbers.

Thank you for your business!

©1998 - 2013 CCO *International shipments quoted individually. In general, they will be more than US.

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