Fax Order Form
Product Name
Unit Price
Shipping & Handling
Quantity
Sub-Total
DHL/UPS
EMS Express
Eye3D Premium (4-in-1)
US$199
US$92
US$70
  
Eye3D Force (3-in-1)
US$69
US$92
US$60
3D Multimedia Player CD
US$50
US$50
US$24
    
Eye3D Wireless GX4000 (Glasses Only)
US$79
US$66
US$40

Eye3D Force Wired Glasses
(Glasses Only)
US$45
US$66
US$40
Total

Personal Data

Name: ________________________________ Country: _________________________

Shipping Address:________________________________________________________
(Please make sure the shipping address is complete, correct and legible in type writing.)

E-Mail: ______________________________________________ (for Order Confirmation)

Phone No: __________________________ Fax No.: ___________________________

Credit Card

Card Holder: _____________________________ Card Issued by: _________________________

Please check: VISA MASTER JCB Card No.: __________________________________

Expired Date: _______ / _______ Signature: ___________________________________________

Card Security Code: __________
(It is the last 3 numbers located at "Signature Area" of the Credit Card.)