My Jewelry Source: diamond jewelry, gemstone jewelry, gold jewelry, platinum jewelry, diamond ring, diamond bracelet, engagement ring, engagement rings, platinum,  tanzanite jewelry, ruby jewelry, sapphire jewelry, emerald jewelry, and diamond rings, diamond bracelets, all at hughly discounted prices.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  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: _____________