California Blackworm CO. Credit Card Purchase Agreement

Complete this form in full and CLICK the submit button at the bottom. Then email to blkworm@aol.com what you would like to order. In the event you cannot use the submit button below, you can print it, fill it out and fax to 559-291-0601 or copy and paste it and email to blkworm@aol.com  Then email direct to blkworm@aol.com what you would like to order. We must have this form on file in for purchases to be made.  

 

California Blackworm Co.
Ph- 559-291-0623            Fax- 559-291-0601
 

Said purchases may be placed on the following credit card:
VISA        MasterCard        American Express

Cardholder Name

Card Number    Exp Date  Code #'s

The following named individuals are hereby authorized to make such
Purchases via telephonic ordering:

#1  Individual: 
#2  Individual:
 
 

                                               Shipping Information                                 

Business Name  

Individual Name

Address

City        State Country Zip or Postal Code

Phone              Fax  

Email      web site 

By typing or signing your name on the following line and submitting this form to California Blackworm Co., you are accepting the conditions as stated above when using your credit card to pay for goods and services from California Blackworm Co.. 

Signature of Cardholder
  Date