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To order by mail, complete this form and mail this form and payment to: ShopFoodSource.com c/o Blue Pike Commerce 901 West 12th Street Erie, PA 16501 Please make checks payable to Blue Pike Commerce SOLD TO: Name: _________________________________________________ Address: _________________________________________________ _______________________________________________________ City: ____________________________ State: ________ Zip: _________________ PLEASE: We really need your phone number to contact you if there is a problem with your order. Daytime Phone: (_______)__________________________________________ Evening Phone: (_______)__________________________________________ Email Address: __________________________________________________ SHIP TO: (Include only if different than your "sold to" information) Name: _________________________________________________ Address: _________________________________________________ _______________________________________________________ City: ____________________________ State: ________ Zip: _________________ Daytime Phone: (_______)__________________________________________ Evening Phone: (_______)__________________________________________ Email Address: __________________________________________________
METHOD OF PAYMENT (No Cash or Stamps)
CSC Code (3 digits for MasterCard, VISA and Discover, 4 digits for AMEX) (Required): ____ ____ ____ ____ (For MasterCard, VISA and Discover: Flip your card over and look at the signature box. You should see a 16-digit credit card number followed by a special 3-digit code. This 3-digit code is your Card Security Code (CSC). For AMEX, look for the 4-digit code printed on the front of your card just above and to the right of your main credit card number. This 4-digit code is your Card Security Code.) CARDHOLDER'S SIGNATURE ___________________________________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||