Please provide the following contact information:

Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Contact Phone
E-mail

Please provide the following ordering information:

QTY	DESCRIPTION

FOR CREDIT CARD ORDERS, PLEASE SEND YOUR CREDIT CARD INFO VIA one of the 4 following methods|


print this form and include Credit card information (cardholder name, credit card #, expiration date)  via fax, telephone, or mail

1) FAX to (916) 723-4228

2) TELEPHONE (916) 723-8528
 

3) MAIL to }
Reflections of Asia
6301 Misty Wood Way
Citrus Heights, CA 95621
USA

4.CREDIT CARD INFORMATION

 cardholder's name

credit card number 

expiration date        

 

	SHIPPING
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country

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