LeanCard.com 4375 Edenwild Ln Corona, CA 92883 Phone: (954) 317-2418 (800) 664-8848 FAX: (866) 470-0140

ORDER FORM

Card Price Quantity Total [   ]   **Super Pin-Less** New $3.00 ______ $________ [   ]   **Super Pin-Less** New $5.00 ______ $________ [   ]   **Super Pin-Less** New $10.00 ______ $________ [   ]   **Super Pin-Less** New $20.00 ______ $________ [   ]   **Super Pin-Less** New $50.00 ______ $________ [   ]   **Super Pin-Less** New $100.00 ______ $________ [   ]   Africa Supreme $5.00 ______ $________ [   ]   Africa Supreme $10.00 ______ $________ [   ]   Africa Supreme $20.00 ______ $________ [   ]   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 ) $3.00 ______ $________ [   ]   Smart Card ( New ) $6.00 ______ $________ [   ]   Smart Card ( New ) $21.00 ______ $________ [   ]   Supreme International $5.00 ______ $________ [   ]   Supreme International $10.00 ______ $________ [   ]   Supreme International $20.00 ______ $________ Total: $________ If more then 10 cards, minus 10% discount: $________ DELIVERY OPTIONS: [   ] E-Mail PINs (FREE)   [   ] Fax PINs (FREE)   [   ] Mail the cards ($2.00) $________

Please provide the following information about yourself:

Last Name _________________________ First Name _________________________ Title _________________________ Company _________________________ Address (billing) ________________________________________________________________ City _________________________ State/Province _______ Zip/Postal code _________________________ Country _________________________ Evening Phone (_____)_______________ Day Phone (_____)_______________ FAX (_____)_______________ E-mail _________________________

Payment Information:

[   ]   Check/Money Order Included [   ]   Credit Card If paying by credit card:   Credit Card Type: [   ] VISA   [   ] MasterCard Number __________________________________________ Expiration Date ____/________(mm/yyyy)

1. PRINT this form.
2. MAIL/FAX completed form to address above.
3. IF FAXING, provide your credit card information.
The information in the fields marked with Bold labels is necessary for us to process your order.
 

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