PEDIWEAR SHOE CENTRE ONLINE Fax Order Form

Please ensure all details are completed then Fax to +44 (0)1422 367609
Customer Details
Name as appears on Credit Card 
       Contact Telephone No.
This number is essential
Card billing address


Post Code/Zip
Country		    
 
 
 
Email   Return Fax No.
Delivery address (If different)


Post Code/Zip
Country		    
  Confirm receipt of order by Fax(YES/NO)
or by email(YES/NO)
 
 

Card Details
Type (Visa/MasterCard/Switch/AmEx)  
Number

 

Valid From      /
Expires      /
Issue Number                           (switch only)

Make Style Size Colour Number Price
           
           
           
Total

    
Shipping cost @      per pair =  
Total to be billed from card  
No charge for shipping for orders from the UK
I confirm the above order, signed_______________ date________ Please sign and date.