Mail/Fax order form

For faxed orders, money orders or bank checks:

    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.