1924 Raymond Drive
Northbrook, IL 60062
Phone: 800-506-7966 / Fax : 206-237-2976
www.crystalartusa.com
SAMPLE REQUEST ORDER FORM
print and fax to
1-206-237-2976
Order No:
Order Date:
/
Purchase Order#:
Billing Information
Customer Name:
Company Name:
Street:
Street 2:
City:
State & Zip:
Phone:
Email:
Shipping Information
Customer Name:
Company Name:
Street:
Street 2:
City:
State & Zip:
Phone:
Email:
Payment Information
Payment Type (check one):
[ ]Visa [ ]American Express [ ]MasterCard [ ]Money Order [ ]Corporate Check
Card Number:
CVV2 Code (on back of card):
Card Expiration Date:
Card Holder Name:
Card Holder Phone Number:
Shipping Information
Shipping Type:
[ ]Next Day [ ] 2Days [ ] 3Day [ ] Ground
Shipping charges will be added to your total.
Special Instructions
Please allow 5-7 business days for standard orders. For rush orders call 773-531-2202.
Items
Inventory #
Product Description/Size
Qty
Price per Unit
Total
$
$
$
$
Totals
Sub Total:
$
Sales Tax * 0.0875 (Illinois ONLY):
$
Total:
$
A sample request is a merchandise purchase of maximum two blank items that can be returned within 7 business days upon receipt of the merchandise.
A full payment for the merchandise, shipping, insurance and handling fees will be charged to the customer's credit card when the merchandise is shipped.
The customer assumes full liability and responsibility for the sample merchandise in transit and at their location.
If the sample merchandise is returned to Crystal Art USA, LLC. within 7 business days; in the original packaging and original condition (brand new),
the customer's credit card will be credited for the cost of merchandise only. Crystal Art USA, LLC will not issue refunds for merchandise returned after
7 business days upon customer's receipt of the merchandise or merchandise returned damaged. Customers are responsible for filing damage claims with
the shipping carrier. The customer agrees to pay all shipping, insurance, and handling charges incurred during shipping the sample items, including
shipping and insurance of the merchandise back to Crystal Art USA, LLC. Shipping and insurance charges will be billed to the customer's credit card
or waived if the customer uses their own shipping account.
By signing this form you agree to these terms for your order.
Signature_____________________________________ Print Name ____________________________________________
Please take a note of the original packaging of the sample merchandise.
