Unqiue Rustique: Order Form

Use this easy form to order any of our items.

The following form is intended to be used for our customers who prefer to order by mail. (The background will print out white.)
To correctly fill out the required fields, simply place all your items into the Shopping Cart (as if you were buying on-line) and go to the "Basket Contents" option on the header taskbar when finished. All information including product description, product codes, chosen size, desired color, quantity and total purchase price will be shown for you to transfer to the manual order form.

Remember, our Secure Online Shopping Cart can be used for your shopping convenience and expedience of your order.

1. Item
Order # Size How Many Color
Price Each
Total

TOTAL COST

An e-mail confirmation will be sent to you with final cost of your order including
shipping & handling and Arizona tax if applicable.

2. Shipping Information:

3. Ship Order To:

Name:
Street Address:
City:
State/Province:
Zip Code:

Local Arizona sales tax will be added where applicable.

4. Billing Information:

Credit card number:
Expiration date:
Credit Card Holder's name:

Credit Card Holder's Billing Address:
Click here, if Credit Card Billing Address is the same as Shipping Address

Address:
City:
State/Province:
Zip Code:

5. Contact Information (Required)

Full E-mail Address:
Daytime Phone:
Evening Phone: (If different)

Comments To Us:
(If your comments do not fit in the lines below, feel free toE-Mail Us about your order.)

Ordering by mail: Make your Money order or check payable to: "Unique Rustique", please include your state and drivers license number for personal checks. Please print a copy of this order form to mail in with your payment. Contact us for shipping costs prior to mailing your order. Orders sent without shipping will be billed the shipping costs prior to delivery.

Home Page

UNIQUE RUSTIQUE
PO Box 6115 Kingman,AZ 86402-6115 USA Phone: (928) 757-5899
E-mail: E-Mail Us

We offer the most secure on line shopping available. Unique Rustique uses SSL 128bit encryption, the highest industry standard for the safest credit card transactions. Through our credit card gateway we never even see your credit card number! Or you can order by phone!