MILITARY SERVICE COIN CO.(MSCOIN.COM), 24HR Credit Card Payment Form

Print out this form and fax it back to (559) 275-5123 With Artwork. 24 Hrs. SVC.



 CUSTOMER INFORMATION:

 Customer ID________________ (assigned by MSCOIN. COM)  Reorder Y / N Order# _____________

 We accept all types:   VISA / Master Card,  Other: ____________________ (* We do not accept Amex & Discover)

 Amount Being Charged (if applicable and for the re-order): $______________________________

 DATE ORDER IS NEEDED:______________

 ORDER
 TYPE:  a. REGULAR w/Sample coin:_____         b. REGULAR NO sample coin:____  c. RUSH ORDER!!!:____

 CREDIT CARD INFO:

 Credit Card#___________________________________________ EXP. Date: ______/______  CVV2 code ______________

 *CW2 Code : Last 3 digits on the BACK of the card of Visa

 Cardholder Name:_________________________________________________________________________________________

 Billing address:___________________________________________________________________________________________

                  ___________________________________________________________________________________________

 Shipping Address: (Same:  YES / NO) _____________________________________________________________________

                   ___________________________________________________________________________________________

 Telephone Number: (DAYTIME) ___________________ _____      (EVE. or CELL.)_____________________________

 E-mail Address for Receipt of Payment & Artwork Approval: _________________________________________________

 Descriptions of Order:

 Quantity of coins: ___________ Coin size:     1.56"  1.75"  2"  Other: ________  (Standard thickness is 3 mm)

 Metal Type: Bronze,  Antique Bronze,  Antique Silver/Gold,  Shiny Silver,  Gold,  Black Nickel,

 Precious Metal Plate:     .999 Silver               24K Gold   

 Color: None 1 side (5 or less on one side)      2 sides (5 or less colors per side) Extra colors? How many? ________ 

 Options: EPOXY / SANDBLASTING / CUTOUTS / SILK SCREENING / NUMBERING / LASER ENGRAVING / PARTIAL PLATING or
 TWO TONE PLATING / KEY CHAINS /  REEDED EDGE / GLOW PAINT / HEAT CHANGING COLOR PAINT / PICTURE INSERT /
 FLAT or TWIST DIAMOND CUT

 We strongly recommend the EPOXY finish to protects the paint, enhances the 3D detail look!

 List any special features here:______________________________________________________________________________

 *Other than coin / pin order, please describe the item and state the Web site pages with Number: _____________

__________________________________________________________________________________________________________

 ********By placing this order, you certify that you are authorized to sign on behalf of the credit card holder, and you agree to our terms
 of service as listed on our web page at www.mscoin.com/termsofservice*******

 

 Signature:________________________________ Date:_______ Print name:____________________________

 

 MILITARY SERVICE COIN CO.(MSCOIN.COM), 24HR Credit Card Payment Form

Print out this form and fax it back to (559) 275-5123 With Artwork. 24 Hrs. SVC.

 

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ㄏAll Rights Reserved 1998-2005 MSCOIN.COM
#5068 W. Wathen Ave. Fresno, CA 93722
Tel:(559) 275-4931   Fax:(559) 275-5123