EKOOSTIK HOOKAH SHOP MAIL/FAX ORDER FORM - PAGE 1 OF 2
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SHIP TO:

Name:_________________________________________________________________________

Street Address:_______________________________________________________________

City:______________________________  State:___________  Zip Code:_____________

Email:_____________________________  Phone Number:____________________________

Best time to call (if we need to contact you):________________________________


PAYMENT/BILLING INFORMATION:

Payment Method: [__] Money Order  [__] Credit Card (fill out the section below)

		[__] Cashier's Check          ** NO PERSONAL CHECKS ACCEPTED **

Name (on card):_______________________________________________________________

Billing Address:______________________________________________________________

City:______________________________  State:___________  Zip Code:_____________

Credit Card:  [__] Visa  [__] MasterCard  [__] Discover  [__] American Express

Card Number:____________________________________  Expiration Date:____________

Signature:____________________________________________________________________


Merchandise Total (from other page)		$[____________]

Shipping Total (from other page)		$[____________]

TOTAL PAYMENT INCLUDED				$[____________]


SEND YOUR ORDER:

Please include BOTH order sheets (this one and the merchandise/shipping page), or
we won't be able to fill your order. Cashier's checks and money orders should be
made payable to "Acoustic Merchandise, Inc.".  Mail your order to:

Acoustic Merchandise
1765 Painter Rd.
Fredericktown, OH 43019

Or fax your order sheets to 419-886-6032. Fax orders are credit card only.