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Fax/Mail Order Form

Fax to (386) 788-7176 or mail with:
Credit Card info, Cashier's Check, Money Order or personal check payable to:
HelmetsRus/Daniele Enterprises, Inc. 857 Taylor Road Port Orange, FL 32127 USA

First Name_______________________ M.I.____ Last Name_______________________________

Address__________________________________________________________________________

Additional Address information _______________________________________________________

City________________________________________ State __________ Zip Code ______________

Phone __________________________________

Qty Description Code Size Price Total
           
           
           
           
           
           
           
           
           
  Shipping/Handling        
  Total Order        

Fill out the following if paying by credit card by mail or for Credit Card Authorization.
Circle Type of credit card: MasterCard Visa American Express

Card Number _____________________________________________ Exp Date _____________

Three or four digit security code on card _______________

Email Address or Fax Number for Order Confirmation __________________________________

Print name on credit card ___________________________________________________________

Cardholder's Signature _________________________________________Date______________

Credit card 800-Number for international Authorization _______________________________________

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