TO :         CasketXpress                                                         Fax Number: (619)265-3455
FROM :
RE :         CasketXpress Faxed Order


Order Form - Cherry Veneer Wood Casket

Product Code - AXV11

Price - $1499.97

The price quoted excludes applicable sales tax, & shipping charges.

Please Specify:
Color ________________________
Quantity  
________________________
Comments:
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
Shipping Address:
Name ______________________________________________________________
Address ______________________________________________________________
City, State, Zip: ______________________________________________________________
Is this address a mortuary or funeral home? Yes/No
Receiving Funeral Information:
(If available)
Contact Name ______________________________________________________________
Phone ______________________________________________________________
Fax ______________________________________________________________
Desired date and time of the funeral viewing/services:
(It is not required to order the casket)
Date ___________________________________________________(DD/MM/YY)
Time ___________________________________________________

Buyer Information:
Title _____
First Name __________________________
Last Name __________________________
Email __________________________
Address __________________________
City __________________________
State _____
Zip __________
Country __________________________
Phone __________________________
Alt Phone __________________________
Fax __________________________
County __________________________
Shipping Options   Please select one:
Ovenight delivery
2 day rush delivery
3 day rush delivery
Overnight Saturday delivery
Standard delivery
Deceased Person Information:
First Name __________________________
Last Name __________________________
Height ___________
Weight
 ___________

Please call our toll free number (800)550-7262 to CONFIRM your order.

Thank you.
CasketXpress.com


Method of Payment 
Bill this order to:
Name as it appears on the card: __________________________
Billing Address ______________________________________________________
Address line 2 ______________________________________________________
City _________________________
State/Province _____
Zip Code __________
Card Number _________________________
Card Type       Please select one:
Visa
Master Card
Discover Card
American Express
Expiration Date        _______________ (DD/MM/YY)
CVV2 _______________ What is CVV2?(Click Here)
Select: Please select one:
I have entered my CVV2 above
My card has no CVV2 imprint
My cards' CVV2 is illegible

I have read and I agree to the Terms and Conditions of Sale (Please click here)


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