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Irish & Victorian Gift Store - Fax Order Form

If you wish to order goods via fax or mail method:
Print completed order form and Fax to Irishvictorian at (+ 1-516) 785 3225
or
Mail to: Irish Victorian Gift Store, The Olde Towne Garden, 1902 Wantagh Ave, NY11793

*Please use the item numbers as shown on our web pages.

*Item No.
Quantity
Description
Size
(if any)
Price each
US$
TOTAL
US$

Total US$

*Add State Tax

Order Total US$

*only applies to New York and New Jersey customers

Name and address details

(*Fields marked red are required to continue)

*Name

*Billing address

*State/Country

*ZIP/Post code

*Telephone

Fax

Email address

Ship to

(if different from above address)

*Payment details: Credit Card Information*

*If you prefer, we will contact you for your credit card details.

Visa Mastercard American Express Discover

Card number:

Cardholder:

Expiry date:

If you should experience any problems in faxing your order, contact us immediately.
 

|Wedding rings | |Jewelry| |Gifts for child| |Gifts for him| |Gifts for her| |Special occasions| |Gifts for the Home|

Irish Victorian Gift Store, The Olde Towne Garden,
1902 Wantagh Ave, Wantagh, NY 11793
Tel: (516) 826 2574; Fax: (516) 785 3225
www.irishvictorian.com
email: info@irishvictorian.com