SECURE DEALER ORDER FORM for WHOLESALE and/or DROP-SHIP ORDERS (Direct-Mail Leads) 

 
Please use this form to submit your CREDIT OR DEBIT CARD Orders to us online via our SECURE SERVER or by fax or mail. This form is for use by our REGISTERED Dealers only.(click here to register - it's FREE!) Please bookmark this page or print copies for future use. Use one form for each individual order. Please print and mail this form if paying by check or money order.
     Name of Cardholder 
                Address 
                   City  State  Zip 
                 Card #  Expires 
          Security Code 
          (The security code is the last 3 digits appearing on the back of your card, 4 digits on the front for American Express.)
 Amount of this order $ 
    Your e-mail address

SHIP TO: (Leave blank if you are mailing us a shipping label)  
     Name 
  Address 
     City  State  Zip
# of Names (Select one) 
200 - $16 
500 - $28 
1,000 - $40 
2,000 - $68 
5,000 - $140 
10,000 - $260 
20,000 - $440 
30,000 - $600

IF THIS IS A DROP-SHIP ORDER, HOW DO YOU
WANT YOUR ADDRESS (AS SENDER) TO READ:  
     Name 
  Address 
     City  State  Zip
Format (Select one) 
Labels 
Via email (standard text file) 
 

Sorting (Select one) 
Random Zip Codes 
Zip Sorted (1,000 minimum)
 
 
Comments/Suggestions:



or print this page and mail your order(s) to:
Paul C Wilson, PO Box 26418, Tamarac, FL 33320
or FAX your credit card order(s) to: 954-344-0996