Couture Clothing  -  Pay by fax - TOTALLY SECURE

Complete the form as below, print it out and fax it to Couture Clothing at  (+61 2) 9567 1254. We will promptly confirm your order by email.

Your Full Name (as it appears on credit card)
Shipping Address
Telephone number
Email address
Credit card type  Visa ; MasterCard; American Express/JCB; Diners Club
Credit card number

 


 
Expiry date on Credit Card
Fill in all items numbers you are purchasing, and fill in advertised price (select currency US$.
 
 
Brief Description
Item #
Price*

Click US$   

Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
 
ORDER SUBTOTAL
  
Add Shipping. (All orders shipped by first class mail, unless otherwise requested.)
 
 
Add $6.50 for orders valued from $1.00 to $9.99
Add $8.50 for orders valued  from $10.00 to $49.99
Add $12.50 for orders valued from $50.00 to $99.99
Add $16.50 for orders valued from $100.00 to $199.99
Add $22.00 for orders valued from $200 up to $450.00
For orders over $451 contact Couture Clothing
 
Amount for Shipping 
Add Order Subtotal to applicable Amount for Shipping to get total amount 
 I authorize Couture Clothing to bill my credit card the total amount of:

US$   
 

Signature on Credit Card (Essential for purchase processing)

 

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Your purchase will appear on your credit card statement as a debit to Couture Clothing.