My Celtic Rings Fax Order Payment Confirmation Form

To Print: Click here or Select File/ Print from your Browser Menu. Then fax or mail as shown below.

My Celtic Rings
3013 N. Ironwood Avenue,
Broken Arrow, OK 74012
FAX: (516) 740-0773

Your ORDER #:_______________________

CREDIT CARD (circle one) Visa MasterCard Discover

Cardholders Name (as it appears on card):____________________________________________________

Account #: ____________________________ Exp. Date: _________

Issuing Bank:_______________________CVV #:_______(what is CVV #)

Bank's Customer Service Phone #(on back of card):________________

Credit Card Billing Address: ( where card statements actually are mailed to you) _________________________________________________________
_________________________________________________________
_________________________________________________________

Your Shipping Address: (skip if same as billing) ___________________________________________________
___________________________________________________
___________________________________________________

Phone #:( )_____________ Email address____________________

I hereby authorize My Celtic Rings to charge my credit card for the purchase of jewelry for the amount of $_______________

Product Order Terms and Conditions
1-Order will be fully paid within 90 days in a single or multiple credit card payments.
2.- Work on order begins once order has been fully paid.

I confirm the product order described above and agree to the terms and conditions listed above.

Name: _____________________________________ Signature: ___________________________________________________

Date:_________________