Mail orders to: 123eRugs.com P.O. Box 1500 Gaffney, SC. 29342 Fax orders to: 1-864-487-0344 Call orders to: 1-866-900-eRUG Mailing Address: Name: _________________________ Address: _______________________ Address: _______________________ City: ________________________ State:_____ Zip:_______ Phone: _____________________ E-mail: ____________________________ For credit card orders, 123eRugs.com ships only to the address of the credit card holder. Ship To: ( If Different from Mailing Address ) Residence: ______ or Business: ______ Name: _________________________ Address: _______________________ Address: _______________________ City: ________________________ State:_____ Zip:_______ Phone: _____________________ E-mail: ___________________________ Product Details: Product Code: Description: Qty: Price Each: Total: ___________ __________________________________________ _____ _________ _________ ___________ __________________________________________ _____ _________ _________ ___________ __________________________________________ _____ _________ _________ ___________ __________________________________________ _____ _________ _________ Total: $_____________ Shipping: $_____________ In SC Add 0.06% Sales Tax: $_____________ TOTAL: $_____________ Method of Payment: _____ Check or Money Order (payable to "123erugs.com")   _____ Mastercard   _____ Visa   _____ Discover _______ Amex Credit card #: ____________________________   Exp. Date: ________ (mm/yy) SecurityCode: _________   (3 digit number on back of card) Name On Credit Card:_________________________________ I authorize 123erugs.com to charge my credit card as payment for the products listed above: Signed: ____________________________   Date: __________ Verification of any lower price offers should be submitted along with your order.