Please PRINT, COMPLETE and FAX to 510-848-3366
Earthquake Gas Valve Source

Berkeley, California, USA

Tel. 510-843-3275 Fax 510-848-3366 www.EarthquakeValve.com

Shipping Address - PLEASE PRINT CLEARLY

First Name _____________________ MI_______ Last Name ___________________________

Company Name________________________________________________________________

Street Address_________________________________________________________________

City, State, Zip_________________________________________________________________

Telephone No. _____________________________Fax No. _____________________________

Credit Card Information - PLEASE PRINT CLEARLY

First Name _____________________ MI_______ Last Name ___________________________

VISA MASTERCARD DISCOVER AMERICAN EXPRESS - PLEASE CIRCLE ONE

Card Number__________________________________________Exp. ____________________

Card Verification Number: (On the back of your card, locate the final 3 digit number)_____________

Telephone No. ______________________________Signature ___________________________

Order / Quote Request - PLEASE CIRCLE ONE

Qty______ Price___________ Description_________________________________ Total_______________

Qty______ Price___________ Description_________________________________ Total_______________

Qty______ Price___________ Description_________________________________ Total_______________

Qty______ Price___________ Description_________________________________ Total_______________

Qty______ Price___________ Description_________________________________ Total_______________

Qty______ Price___________ Description_________________________________ Total_______________


Total ___________________________________________

California Sales Tax 9.75% __________________________

Shipping & Handling _______________________________

Total ___________________________________________
USA Orders: 4.5% Charge Card Processing fee
(multiple the total amount by 0.045)_____________________
INTERNATIONAL Orders: 5.9% Charge Card Processing fee
(multiple the total amount by 0.059)_____________________

Grand Total ______________________________________

Shipping & Handling Fees*: .
Within the (48) USA - excluding Special & International Orders.
Up to $78.99: $24.95 -
$79-$134.99: $14.95...
$135-$749.99: $24.95 -
$750 and up: Free
*See the Order page for additional terms and conditions.
*INTERNATIONAL SHIPPING
PLEASE NOTE THAT THE PRICE QUOTED FOR SHIPPING TO YOUR COUNTRY WILL NOT INCLUDE ANY DUTIES OR CUSTOMS CHARGES THAT WILL BE CHARGED BY YOUR COUNTRY. WE CAN NOT QUOTE DUTIES OR CUSTOMS CHARGES FOR YOU. WE WILL NOT UNDER ANY CIRCUMSTANCES ACCEPT RETURNS RELATING TO UNPAID OR REFUSED DUTIES OR CUSTOMS CHARGES. IF THE ITEM COMES BACK TO US, YOU WILL BE RESPONSIBLE FOR PAYING POSTAGE TO HAVE THE ITEM REDELIVERED.

Notes