Member of the Internet Link Exhange
Web Sampler Mail-In Order Form

Print one form for each merchant you are ordering from.  
Form must be mailed or faxed to the  respective merchant.
DO NOT send to the Web Sampler!

I. General Information

Date___________

Do you want to be entered into the Web Sampler Prize Drawings?  YES/NO

Name__________________________________________________

Address_______________________________________________

City_____________________  State_______  Zip__________

Phone__________  Fax__________  Email_________________


II. Ordering Information

NOTE:  Specify any color, size, or other unique product attribute.

Merchant: ___________________________

 Product Code   Product Description                 Qty     Unit Price

_____________   _________________________________   _____   __________

_____________   _________________________________   _____   __________

_____________   _________________________________   _____   __________

_____________   _________________________________   _____   __________

_____________   _________________________________   _____   __________


				Sales Tax (if applicable)   __________

						   TOTAL    __________

Note: Applicable S&H charges will apply. See merchant homepage for S&H.

Special Instructions_____________________________________________________

_________________________________________________________________________

_________________________________________________________________________


III. Billing Information

Method of Payment (Please circle): Ck/MO/MC/VISA/Disc/AE
(NOTE: Check with merchant to verify acceptable payment methods)

Credit Card Number: ____________________  Exp.(month/year): _________

Name as appears on credit card:______________________________________


IV. Shipping Information

Shipping Address (if different than above)

Address: ______________________________________________________________

City:___________________ State: ______ Zip: _______ Country: __________

Thank you very much for your order.

Mail or FAX Completed Form to Appropriate Merchant