Bowery Lighting Co.
Fax Order Form
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Bill to:
Customer Name:
First: ________________________
Last: ________________________
Customer Address
_______________________________
_______________________________
_______________________________
_______________________________
Customer Phone Number: ______________________
Customer Fax Number: ______________________
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Ship to: (If Different)
Customer Name:
First: ________________________
Last: ________________________
Customer Address
_______________________________
_______________________________
_______________________________
_______________________________
Customer Phone Number: ______________________
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Payment Method: Check or Credit Card (circle one)
Card Number: __________________________________________
If using check we will contact you with and for further information. If you are uncomfortable with listing your credit card information on this form, we will call you upon receipt and review of your order form.
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How would you like us to ship your order?
_____ United States Priority Mail (average of 2 – 3 days for delivery)
_____ United States Express Mail (next day delivery)
To confirm your order, pricing, shipping and give you an order number how can we reach you? Phone or Fax (circle one)
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