ORDER FORM

Please print this ORDER FORM and mail or fax it with your credit card information, check, or money order to:

WEST COAST HARDWARE

Phone:

(323) 3520-4017

516 Bastanchury Ave

Henderson, NV.  89011

U.S.A.

Mon.-Fri-:  8:30am-6:00pm PST

Electronic Mail: WcHardware@msn.com

Saturday:  9:00am-3:00pm PST

Item

Price

Quantity

Total

Subtotal

S&H

Grand Total

Page 1 of 2

Customer's Billing Information:

(Please print clearly)

(Complete below then sign and date only if mailing or

faxing your order. Do not fill-in if order is to be emailed.)

Name:

Credit Card Number:

Address:

City:

Expiration Date:

State:

Zip Code:

CVV/CID Number:

Country:

(3-Digit Security Code on the back of Payment Cards or

4-digit security code on front of American Express card.)

Email:

For emailed orders your phone number is required to complete your order:

Phone Number :

For mailed or faxed orders your signature is required:

Sign:

Date:

Customer's Shipping Information:

(If different from above)

Custom Order Instructions:

Address:

City:

State:

Zip Code:

Country:

Page 2 of 2

Thank you for shopping at WCHardware.com!