Print this
form and mail or fax it
to American Dream Passport
American Dream
Passport
4023 East Grant Road, Tucson AZ
85712
Phone Toll-Free 1-800-320-6660
Fax 1-520-325-8950
To ensure proper processing,
please note your supplier is
Polley Associates 9804
Ship To:
Name:
________________________________________________
Address_______________________________________________
City ______________________ State
__________ Zip __________
Phone
_________________________________________________
Fax
___________________________________________________
E-Mail
______________________________________________________
Company_______________________________________________
Order Information:
_____ 10 passports at $39 + $5
for shipping and handling = $44
_____ 25 passports at $79 + $6
for shipping and handling = $85
_____ 50 passports at $149 + $8
for shipping and handling = $157
_____ 100 passports at $275 + $15
for shipping and handling = $290
For quantities over 100, please
call 1-800-320-6660 for pricing
Arizona residents MUST include 7%
sales tax
$_________ Passports
$_________ Sales Tax (AZ 7%)
$_________ Total
Payment Method:
____ Check Enclosed _____
Visa _____ MasterCard
_____ Amex
Card No. ________________________
Expires _______________
Name On Card
__________________________________________
Signature
______________________________________________
© Copyright 1998 American Dream
Passport™. All Rights Reserved |
