COMPLETE & PRINT PRINT
this form, then MAIL or FAX it to the address at the end of the order form
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How did you hear about us?
I have enclosed a check. Payable to: Kimbrell, Inc. Check
one:
Visa
Master Card Enter Credit Card Number:
Expiration Date: Month
Year
Security Code
(Last 3 digits on the back of the card)
X_____________________________________________
Authorized Signature on above credit card
Purchase Order Attached P.O. Number:
School
Districts, Non-Profits,
Fax signed P.O. to 562-420-9101
Corporations, etc.
Billing Information
(Address & phone must
match where your credit card bill is sent)
Contact Name
E-mail
Telephone
Fax
Company
Address
Address2
City
State
Zip
Check here if billing is the same as shipping
Shipping Information
Contact Name
E-mail
Telephone
Fax
Company
Address
Address2
City
State
Zip
How did you hear about Patty?
I would like a
confirmation of this order sent to me via
(check
one)
Fax
E-mail
Print &
Complete this form. FAX to 858-485-7758
or MAIL to: Kimbrell, Inc., 11226 Trailside Court,
San Diego, CA 92127
