Fax Order Form
Product Name
Unit Price
Shipping & Handling
Quantity
Sub-Total
DHL/UPS
EMS Express
Cinema3D
US$399
US$92
US$60
    
Cinema3D Player CD
US$150
US$50
US$24
Cinema3D Infrared LC Shutter Glasses
US$59
US$66
US$40
    
Cinema3D Wired LC Shutter Glasses
US$45
US$66
US$40
Hyper3D System Hyper3D Controller
US$500
US$66
US$40
00
0000
Hyper3D Emitter
US$100
US$66
US$40
00
00
Hyper3D Glasses
US$125
US$66
US$40
00
00
Total

Personal Data

Name: ________________________________ Country: _________________________

Shipping Address:________________________________________________________
(Please make sure the shipping address is complete, correct and legible in type writing.)

E-Mail: ______________________________________________ (for Order Confirmation)

Phone No: __________________________ Fax No.: ___________________________

Credit Card

Card Holder: _________________________ Card Issued by: __________________________

Please check: VISA MASTER JCB Card No.: _______________________________

Expired Date: _______ / _______ Signature: ________________________________________

Card Security Code: __________
(It is the last 3 numbers located at "Signature Area" of the Credit Card.)