****  PRODUCT ORDER FORM  ****

FPC INTERNATIONAL, DEPT OP
Box 225
Chappell, NE  69129
USA
 
FIRST: Print this then fill out clearly & completely.  Mail with payment,
OR place credit card orders by FAX: (503) 214-8057 or phone 1-866-533-8218.

Your Name __________________________________  E-mail: __________________

Company Name, if applicable ____________________________________________
  
Shipping Address (no POs)  _____________________________________________
  
Address line 2  ________________________________________________________
  
City, State (Prov/Reg), and Zip ________________________________________
   
COUNTRY:

Contactable Phone # at shipping address ________________FAX: ___________ 

Items Ordered: 
QUANT.  ITEM#     ITEM NAME/DESCRIPTION        PRICE EACH  TOTAL PRICE


  






  
SHIPPING COSTS FROM SHIPPING QUOTE OR SHIPPING TABLE BELOW:    __________

  TOTAL ORDER  (ADD ALL LINES)                             $_____________ 

Thank You for your order!  We really appreciate your business !        
=========================================================================

METHOD OF PAYMENT: CHECK: #__________  MONEY ORDER: #___________________

___ PAYPAL       YOUR PAYPAL EMAIL ADDRESS:___________________________
    
___ Credit/Debit card >>>>> COMPLETE THE SECTION BELOW:

Type of Card:  Visa ___      MasterCard___      Discover: _____

Name on Credit Card: _____________________________

Credit Card Number: ___________________________________ 
Exp date: ________             (3 DIGIT CARD SECURITY #) C V V # _________

CardHolder Name (please print):

Card Billing Address, if different:



Signed _____________________________________ 
         (must be signed by cardholder)





MAKE CHECKS & MONEY ORDERS PAYABLE TO: FPC INTERNATIONAL.
MAIL TO ADDRESS AT TOP OF PAGE 1.





--------- S H I P P I N G   T A B L E ----------

ALL AMOUNTS BASED ON THE US DOLLAR TOTAL AMOUNTS AND COSTS
ARE IN US DOLLAR AMOUNTS BELOW.  ADJUST FOR OTHER CURRENCY.

For ALL mail orders, the shipping & handling rates are:
below $50.00................. add $7.00
$50.00 to 100.00............. add $12.00
$100.01 to 200............... add $15.00
$200.01 to 300............... add $20.00
$300.01 or more.............. please call us.

For orders with tips only or transfers only, add only $3 (instead) no
matter how many tips (or transfers) are ordered or what the total
price of goods is.  These will be sent First Class Mail or Letter Post.
We use the US Postal Service for shipment unless you request a different
carrier or delivery service.  Please add insurance on orders over $50.

INSURANCE
(Amount for Merchandise
Insurance Coverage Desired)    -  Fee
 
50.01 to 100                     $2.05 
 
100.01 to 200                     2.45 
 
200.01 to 300                     4.60 
 
300.01 to 400                     5.50 
 
400.01 to 500                     6.40 
 
500.01 to 600                     7.30 
 
600.01 to 5,000                  $7.30 plus $0.90 per $100
or fraction thereof over $600 in declared value.  (Maximum liability is $5000)