Mail and Fax form

Mail and Fax form

Use this form to provide information about yourself and your product needs.

Please provide the following contact information:

Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail

Please provide the following ordering information:

QTY	ITEM # or DESCRIPTION

	BILLING
Credit Card #
Account name
Expiration

	SHIPPING
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country

Do you have any questions?

Simply fill in this form, print it out, and fax it in or call us!

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Asian Impressions, 2101 Crystal Plaza Arcade #154, Arlington, VA 22202
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