Fax Order Form

ValleyPopCorn.com
Your Complete Popcorn Supply Shop

MAIL / FAX ORDER FORM
(920) 722-CORN (2676)
FAX: (920) 232-1630

ValleyPopCorn.com
Valley Popcorn Company, Inc. 6172 Dixie Road Neenah, WI 54956

Bill To: Ship To:

Name:	.	Name:	.
Address:	.	Address:	.
City, State ZIP:	.	City, State ZIP:	.
e-mail:		e-mail:
Phone:	( )	Phone:	( )
Fax:	( )

Order:

Item #	Item Description (include any options, etc.)	Manufacturer	Qty.	Price	Extended
				$	$
















				Shipping	TBA
				Total	$

Payment Info:

Note: These are the only forms of payment we accept (we do not accept personal checks).

------------------------------------------------ Card Number -------------------------------------------

Exp

Credit Card V-Code:

For your security, and for credit card fraud prevention, we require the V-Code on your credit card. This number is separate from your regular card number and only appears on your card. Visa, MasterCard, and Discover card holders should flip your card over. You will see your 16 digit card number followed by another 3 digits. This is your V-Code. American Express card holders will find their V-Code as 4 digits just above the card number.

_______________________________________________
Signature of Cardholder…must match "Bill To" name above.

I authorize Valleypopcorn.com to charge the credit card number indicated above for the total above plus sales tax (if applicable). I certify that the credit card number and signature above agree to the "Bill To" name above and that, as such, I am an authorized signer on this card.