MyJewelrySource Mail or Fax Order Form

Fax Order Form

To fax us an order, please print this blank form using your browser. Complete the form and fax the completed form to 1-817-549-1037

If you wish to place a phone order instead or have any questions, please call us toll free at 1-866-432-4936 or send an email to service@myjewelrysource.com.

Qty	Item #	Brief Description	Gold (w/y/14k/18k)	Cost	Size	Sizing Fee	Total




Shipping Rates: USPS Priority Mail (all order totals under $250): FREE UPS Ground: FREE UPS 2nd Day: $10 Overnight: $20.00 Alaska/Hawaii: $15 2nd Day/$30 Overnight Special Instructions: Gift Card Message:			Subtotal:
			We pay your CA Sales Tax:				0.00
			Shipping (see chart at left):
			Total:

Customer Billing Address:		Shipping Information (skip if same as billing)
Name:	_____________________________	Name:	_____________________________
Address:	_____________________________	Company:	_______________________(if applicable)
	_____________________________	Address:	_____________________________
City:	_____________________________		_____________________________
State:	_____________________________	City:	_____________________________
Zip:	_____________________________	State:	_____________________________
Phone:	_____________________________	Zip:	_____________________________
Email:	______________________ (optional)

Payment by Credit Card:	Circle One:	VISA Master Card American Express Discover
Credit Card Number:		_______ _______ _______ _______ Expiration:___/___
3 Digit Verification #:		_________ Visa, MC: last 3 digits on signature strip \| Amex: 4 digits on front of card
Name as it appears on the card:		_________________________
By signing below, you are verifying that you are the credit card holder and are authorizing us to charge your credit card
Signature:		_________________________ Date: _____________