Brookhouse fax-order form for credit card payment

Print this form by going to the File menu of your browser and click on “print”. Determine which product(s) you wish to order from the table on the Pricing, Order and Payment page for your country or region. Fill in all the fields below and fax the completed form to the following Brookhouse fax number: +64 9 5354767 (substitute your international dial prefix for the +)

You will receive confirmation of your order by email.

Shipment and billing details

Name:
Street:
Town/City:
State/ Province:
ZIP / Postal Code:
Country:
Daytime Phone Number:	Fax:
Email address:

Order details

Product Code	Product Description	Qty	Price each	Total
Flat rate for freight by airmail (from pricing/order page):
Optional upgrade to courier delivery (from pricing/order page):
ORDER TOTAL

Credit card details

Card type (Visa/Master Card):
Card number:		Valid thru:
Name on card (exact):
Authorization: I Authorize Brookhouse to charge the amount of the “ORDER TOTAL” above to my credit card.	Signature: