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Online Cigar Order Form

 

 

CUSTOMER INFORMATION

*Fill all blanks to process order

 

FULL NAME (FIRST AND LAST NAME)*

POSTAL ADDRESS*

CITY*

STATE/COUNTRY*

ZIP CODE/POSTAL CODE*

TELEPHONE (ARE CODE) + (PHONE NUMBER)*

EMAIL ADDRESS*

 

ORDER INFORMATION

 

DESCRIPTION OF ITEMS TO PURCHASE\

(Please provide specific description of the items or products you wish to purchase)

 

PAYMENT INFORMATION

VISA CREDIT CARD

MASTERCARD

Mark if credit card is from a bank and provide the name of the bank

CARDHOLDER'S NAME (As it appears on the credit card)

CREDIT CARD NUMBER

CREDIT CARD EXPIRATION DATE

 

security code

 

 

SHIPPING INFORMATION

Mark if the shipping address is the same as the postal address

 

LOCATION NAME

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CITY

STATE/COUNTRY

ZIP CODE/POSTAL CODE

TELEPHONE (ARE CODE) + (PHONE NUMBER)

EMAIL ADDRESS

 

I have read the Order Procedures

 

 


 
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