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Mail/Fax/Electronic Check order form

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Mail/Fax/Electronic Check order form

     Quantity              Description of Item and Item Number                Unit Price          Total     
  
     
 
      
 
      
 
      
 
      
 
      
 
      
 
      
 
      
 
      
 
      
                                                                                                        Subtotal                     
                                                                    Illinois Residents add 6.25% tax    
                                                                                                   Grand Total  


Ship To:

Name:___________________________

Address:___________________________________

City:_______________________ 

State:_________________Zip:________

Phone:___________________________ 

Email Address: ________________________________

Bill To (if paying by credit card, this should be the address where the bill is sent):

Name:___________________________

Address:___________________________________

City:_______________________ 

State:_________________Zip:________

Phone:___________________________

Email Address: ________________________________

CREDIT CARD AUTHORIZATION: 

[__] Visa [__] MasterCard [__] Discover [__] American Express

Card Number: ____________________________ 

CVV Code (3 digit number on back of card):  ______________

Card Holders Name as it appears on the card: ______________________________________

Expiration Date: ____________

Card Holders Signature: ____________________________________________

Please send Certified Checks or Money Orders, payable in U.S. Funds to: 
SI Enterprises
1121 S. Roosevelt
Harrisburg, Illinois 62946
When paying with a Money Order or Certified Check, please allow time for funds to be deposited and cleared.

You may call (618) 841-1580 to order or if you have any questions.
You may fax your order to (618) 253-3198.

To Order by Electronic Check

 
 Click Here