Shower Curtain Lock ORDER FORM	For easy ordering of the amazing Shower Curtain Lock, just print out this form, fill out the sections below, and mail or fax it to:
Fax: 702 876-1701 Phone: 877 876-5036 email: info@showercurtainlock.com	Shower Curtain locking Systems P.O. Box 750040, Las Vegas Nevada 89136

Credit Card Billing Name & Address

Name
Address:
City
State	Zip

* Phone:

* Voicemail / Extension / Messg. Svc. / Code

* Email:

Credit Card Information

Card Type: (Discover, Mastercard, Visa, American Express)

Card #

Expiry Date:

Shipping Name and Address (if different from Credit Card billing)

Name
Address:
City
State	Zip

Quantity & Price:

Number of Single Locks (1 per package)

@ $9.95 each

Number of Double Locks (2 per package)

@ $15.95 each

Shipping & handling (United States)

@ $4.00

Shipping & handling (Canada)

@ $6.00