LeanCard.com
PO. Box 35711
Tulsa, OK 74153 |
Phone: (954) 317-2418
(800) 664-8848
FAX: (866) 470-0140 |
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ORDER FORM
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| Card |
Price |
Quantity |
Total |
| [ ] **Pin-Less Star | $3.00 | ______ | $________ |
| [ ] **Pin-Less Star | $5.00 | ______ | $________ |
| [ ] **Pin-Less Star | $10.00 | ______ | $________ |
| [ ] **Pin-Less Star | $20.00 | ______ | $________ |
| [ ] **Pin-Less Star | $50.00 | ______ | $________ |
| [ ] **Pin-Less Star | $100.00 | ______ | $________ |
| [ ] *Pin-Less Jordan | $3.00 | ______ | $________ |
| [ ] *Pin-Less Jordan | $5.00 | ______ | $________ |
| [ ] *Pin-Less Jordan | $10.00 | ______ | $________ |
| [ ] *Pin-Less Jordan | $20.00 | ______ | $________ |
| [ ] *Pin-Less Jordan | $50.00 | ______ | $________ |
| [ ] *Pin-Less Jordan | $100.00 | ______ | $________ |
| [ ] *Pin-Less Pakistan | $3.00 | ______ | $________ |
| [ ] *Pin-Less Pakistan | $5.00 | ______ | $________ |
| [ ] *Pin-Less Pakistan | $10.00 | ______ | $________ |
| [ ] *Pin-Less Pakistan | $20.00 | ______ | $________ |
| [ ] *Pin-Less Pakistan | $50.00 | ______ | $________ |
| [ ] *Pin-Less Pakistan | $100.00 | ______ | $________ |
| [ ] *Pin-Less Syria | $3.00 | ______ | $________ |
| [ ] *Pin-Less Syria | $5.00 | ______ | $________ |
| [ ] *Pin-Less Syria | $10.00 | ______ | $________ |
| [ ] *Pin-Less Syria | $20.00 | ______ | $________ |
| [ ] *Pin-Less Syria | $50.00 | ______ | $________ |
| [ ] *Pin-Less Syria | $100.00 | ______ | $________ |
| [ ] Africa Supreme | $5.00 | ______ | $________ |
| [ ] Africa Supreme | $10.00 | ______ | $________ |
| [ ] Africa Supreme | $20.00 | ______ | $________ |
| [ ] Al-Dinar | $5.00 | ______ | $________ |
| [ ] Domino | $10.00 | ______ | $________ |
| [ ] Golden Dream | $5.00 | ______ | $________ |
| [ ] Middle East | $10.00 | ______ | $________ |
| [ ] Premium Middle East | $5.00 | ______ | $________ |
| [ ] Premium Middle East | $10.00 | ______ | $________ |
| [ ] Premium Middle East | $20.00 | ______ | $________ |
| [ ] Smart and Clean Card | $5.00 | ______ | $________ |
| [ ] Smart and Clean Card | $10.00 | ______ | $________ |
| [ ] Smart and Clean Card | $20.00 | ______ | $________ |
| [ ] Smart Card ( New ) | $6.00 | ______ | $________ |
| [ ] Smart Card ( New ) | $11.00 | ______ | $________ |
| [ ] Smart Card ( New ) | $21.00 | ______ | $________ |
| [ ] Supreme International | $5.00 | ______ | $________ |
| [ ] Supreme International | $10.00 | ______ | $________ |
| [ ] Supreme International | $20.00 | ______ | $________ |
| [ ] Welcome Card | $10.00 | ______ | $________ |
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| Total: | $________ |
| If more then 10 cards, minus 10% discount: | $________ |
| DELIVERY OPTIONS:
[ ] E-Mail PINs (FREE)
[ ] Fax PINs (FREE)
[ ] Mail the cards ($2.00) | $________ |
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Please provide the following information about yourself:
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| Last Name |
_________________________ |
First Name |
_________________________ |
| Title |
_________________________ |
Company |
_________________________ |
| Address (billing) |
________________________________________________________________ |
| City |
_________________________ |
State/Province |
_______ |
| Zip/Postal code |
_________________________ |
Country |
_________________________ |
| Evening Phone |
(_____)_______________ |
Day Phone |
(_____)_______________ |
| FAX |
(_____)_______________ |
E-mail |
_________________________ |
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Payment Information:
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| [ ] Check/Money Order Included |
[ ] Credit Card |
| If paying by credit card:
Credit Card Type: |
[ ] VISA [ ] MasterCard |
| Number |
__________________________________________ |
| Expiration Date |
____/________(mm/yyyy) |
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