Order Form

Thank you for selecting from the online gallery at Atlas Antiques. Please complete this form and return it to us by clicking on the send button.  If you are unable to submit this form online, then print your completed form and send it via FAX to 212.555.1235 or mail it to Atlas Antiques, 235 Shoreline Drive, Fariview, New York 08429. Your satisfaction is guaranteed.

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Order Form

Product

Item

Description

Price

Qty.

Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

       

Subtotal

 

       

Tax

 

       

Total

 


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Shipping Address

Name

 

Address

           

City

    State

Country

       Zip

Email

 


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Billing Address
  Check if same as shipping address

Name

 

Address

           

City

    State

Country

       Zip

Email

 


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Billing Information

Credit card

 

Name on Card

 

Card number

 

Expiration

 


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