Oriental Rug Cleaners Fax Order Form

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Fax/Mail Orders

To fax or mail orders, please fill out the following fields. Print out this page and fax to (901) 475-0581, or mail to:
Oriental Rug Cleaners
988 Jack Bennett Rd.
Brighton, TN 38011

You will be contacted by e-mail that your order is being processed. This form is NOT able to be submitted by e-mail; therefore, your credit card information will not be transmitted. For orders of more than three products, print additional pages.

Name
Address
City
State
Zip or Postal Code
Country
Billing Address (as noted on your credit card statements
E-mail
Contact Phone Number
Method of Payment Telecheck	Credit card
Credit Card Information:
Type
Expiration Date	Month Year
Card Number
Bank Account Information (if paying by Telecheck)
MICR Number (at bottom of check
Check Number
Name(s) as Found on Check
Address as Found on Check
City, State
Zip Code
Driver's License Number
E-mail
This is a personal account business account
*Merchandise Ordering:*
Product 1:
Type
Name or Product Number
Number Ordering
Total
Product 2:
Type
Name or Product Number
Number Ordering
Total
Product3:
Type
Name or Product Number
Number Ordering
Total
Shipping Costs
Tax (if applicable)
Final Total*

*Tennessee Residents Pay .0825% sales tax
Shipping:
0-$29: $4.95
$30-$49:$5.95
$50-$99:$7.95
$100-$299:$9.95
Amounts over $300: 4% of total cost
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Thank you for your order!