The House of Rice Store 3221 N. Hayden Road Scottsdale, AZ. 85251 toll free (877)469-1718 Fax (480) 947-0889 PHONE / FAX / MAIL ORDER FORM Name____________________________________________ SHIPPING ADDRESS_________________________________ Suite or Apt. number_________________ CITY___________________STATE______ZIP__________ Phone # (________)__________________________ The following information is where the charge card bill is mailed to. If it is the same as above, write "Same". Skip the following information if paying by money order. BILLING NAME_______________________________________ Visa, MasterCard, American Express and Discover. CARD #________-_________-________-_______EXP___/___ CVV#________(on Visa, MasterCard, Discover the 3 digits are located on the very right hand side of signature box. On AMEX, the 4 digits are printed on the front right of card)Skip if paying by Money order. Quantity/Item #/ Description / color,size / price/ total _____/_________/______________/_______/_________/_______ _____/_________/______________/_______/_________/_______ _____/_________/______________/_______/_________/_______ _____/_________/______________/_______/_________/_______ _____/_________/______________/_______/_________/_______ _____/_________/______________/_______/_________/_______ _____/_________/______________/_______/_________/_______ sub-total__________ shipping __________ total ____________ Shipping/handling rate chart: Up to $10.99 $5.95, $11.00 to $19.99 $6.95, $20.00 to $29.99 $7.95, $30.00 to $39.99 $8.95, $40.00 to $49.99 $9.95, $50.00 to $59.99 $10.95, $60.00 to $69.99 $11.95, $70.00 to $79.99 $12.95, $80.00 to $99.99 $13.95, 100.00 to 109.99 $14.95, 110.00 to 139.99 $15.95, $140.00 and up $16.95 *If you pay with a personal check, orders will be held 2 weeks for the check to clear. If you pay with a money order, your order will be processed right away. Check or circle one: ____ UPS GROUND (to a home or apt.), ____ UPS Commercial (to a business/office location), ____ US priority mail For other UPS services or FOR SHIPMENTS OUT OF THE UNITED STATES, please call or write for rates. Thank you for your order! *Orders are normally sent out within 48 business hours of receipt unless paid for with a personal check. |
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