MOUSEPAD.COM
 Phone: 800.MOUSEPAD
               626.796.3100

Special RugPad Order Form

 Attn: Fax No: (626) 796-3109
At:MOUSEPAD.COM Date:

Any Controversy or claim arising out of or relating to this contract or the breach thereof shall be settled by the arbitration in accordance with the Uniform Rules for Better Business Bureau Arbitration, and the judgment upon the award rendered by the Arbitration(s) may be entered in any court having jurisdiction thereof.

Please Fill Out and Fax Back to : (626) 796-3109

Min. Quantity (10 mix ok)

Quantity

Type: Agra, Andean  

  Inca, Mustard Isfahan, Medallion, Tabriz
Special Oriental RugPads:    
Special Oriental RugPads:    
Special Oriental RugPads:    
Special Oriental RugPads:    

Where do You Want these Mousepad Shipped?
Company Name:
Attn To:
Address:
City, State, Zip, Country
Phone

 (       )

Fax

 (       )
Email:

How Would you Like to Pay for These Mousepad?
Credit Card Name:

 Visa* [  ]         MasterCard* [  ]         Company Check [  ] *Credit Card processing fee 2.7% extra

Credit Card Number:
Expiration:      
Cardholder's Name:
Billing Address:
City, State, Zip, Country

NO Orders will not be processed without a Signature of Authorization

Authorization (Please Fill Out This Part Completely)
Quote #:

Quoted Price:

$                  /pad
Name (Please Print):

 (Required) 
Authorization Signature:

 (Required)

Notes: Use Blank page if needed