(SAMPLE)
Sample Order Form

By submitting this form you authorize YOUR COMPANY, at ADDRESS, to draft a check on your bank account for the amount shown below if paying by check. You will receive a copy of the check in your next monthly bank statement. If paying by credit card you agree to abide by your cardholder agreement and by pushing submit you agree to the charges you submit.
Please provide the following information for billing.
 
Name on Check or Card 
Company Name (If Any) 
 Address  
 City   State   Zip
 Phone Number 
 email Address 

Bank Name 
Bank City
 Bank State 



 


Check # 

 

 

 
Pay to the order of:  Your company name  *******************

 

 

$

 

 

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PRODUCT:


Option AOption BRadio Buttons
Check Boxes
Scrolling Text Box
Text Box
Mix and match the components to make the order section you desire.  List your products, prices, order numbers and more.

 

*By entering the amount and pressing submit you agree to allow YOUR COMPANY to draft a check for the above amount if paying by check. You also agree to the terms and conditions of your credit card agreement. All returned checks will be subject to a collection fee not to exceed $35 and will vary from state to state. Declined or disputed credit cards are subject to a $49 processing fee. By submitting this order you agree to use the payment method above to pay for the entire order.

 

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