Coughlin's Order Blank

< Coughlin's Order Blank

Coughlin's Order Blank

All blanks with an * MUST be filled in for your order to be honored. We think to highly of our customers to sell or let anyone have our mailing lists or the phone numbers of our customers. We use encryption (Up to 128 bit depending on whether or not your have your browser updated to that) with Netscape Communicator and IE Explorer Browsers. Thank You.
To use this form, type information in the blank and tab to next blank, all the way thru the form.

IF You are ordering and paying by credit card, you must supply us with the billing address for the card you are using. We process by computer, and the wrong address will cause your card to be rejected, not allowing us process your order. This address verification protects you.


*First Name:  
 Middle Initial:  
*Last Name:  
*E-mail Addr:   
 Company: 
*Mailing Address: 
 Address: 
 Address: 
*City: 
*State: 
*Zip Code: 
*Country:  
 Country Code: 
*Home Phone: 
 Home Fax: 
 Work Phone: 
 Work Fax:

Please list below the sale or Special Offer # you are ordering from Example: PTS#77 or SPO#1 (SPO for special Offer). Please type as shown, not leaving a space between the sale (ex: PTS#)and the number(ex:80). I am Ordering from: Lot Numbers:

Comments:

We Accept these cards.
6ccards

I authorize Coughlin's to Charge My Credit card for this order.

ALL Blanks must be correctly filled out. Mailing address above must be the mailing address where card is billed to, for us to be able to process your card.

Exact Name On Card:

Credit Card #:

Expiration Date:

We accept this card, but Discover has regulations against us accepting it from the internet without a large cost to us. Therefore, if you wish to pay using this card we will accept the order from the net, and hold the material for 10 Days while waiting for your signed hard copy of our printed sale. If you do not receive a hard printed copy of the sale, you may send us a letter or postcard with the following information printed on it:
"I AUTHORIZE COUGHLIN'S TO PROCESS MY INTERNET ORDER FROM _________(PRIVATE TREATY OR SPECIAL OFFER # IN THE BLANK) ON MY DISCOVER CARD SENT ON THE INTERNET ORDER FORM.
The Letter or Postcard authorizing the sale MUST be signed and have your address on it also.

Our Land Line # is:
870-376-4520

Our snail mail address is:
224 Turnberry Ct.
Mountain Home, AR.
72653-4179

Please check your order. If it is OK, click the Submit Order button.
The "Clear Form" button will clear the data in the form making it blank again allowing you to retype the data needed into the form.

(submit this order) (clear this order)

Table of Contents Send E-Mail

Last Update: 08/29/2005
Web Author: Ray L. Coughlin
Copyright Š2005 by Coughlin's - ALL RIGHTS RESERVED

Table of Contents Send E-Mail

Last Update: 08/11/2009
Web Author: Ray L. Coughlin
Copyright Š2010 by Coughlin's - ALL RIGHTS RESERVED

Coughlin's Order Blank

Coughlin's Order Blank

To use this form, type information in the blank and tab to next blank, all the way thru the form.

IF You are ordering and paying by credit card, you must supply us with the billing address for the card you are using. We process by computer, and the wrong address will cause your card to be rejected, not allowing us process your order. This address verification protects you.

*First Name: Middle Initial: *Last Name: *E-mail Addr: Company: *Mailing Address: Address: Address: *City: *State: *Zip Code: *Country: Country Code: *Home Phone: Home Fax: Work Phone: Work Fax:

Please list below the sale or Special Offer # you are ordering from Example: PTS#77 or SPO#1 (SPO for special Offer). Please type as shown, not leaving a space between the sale (ex: PTS#)and the number(ex:80). I am Ordering from: Lot Numbers: Comments:

We Accept these cards.

I authorize Coughlin's to Charge My Credit card for this order.

ALL Blanks must be correctly filled out. Mailing address above must be the mailing address where card is billed to, for us to be able to process your card.

Exact Name On Card:

Credit Card #:

Expiration Date:

"I AUTHORIZE COUGHLIN'S TO PROCESS MY INTERNET ORDER FROM _________(PRIVATE TREATY OR SPECIAL OFFER # IN THE BLANK) ON MY DISCOVER CARD SENT ON THE INTERNET ORDER FORM.

The Letter or Postcard authorizing the sale MUST be signed and have your address on it also.

Our Land Line # is: 870-376-4520

Our snail mail address is: 224 Turnberry Ct. Mountain Home, AR. 72653-4179

Please check your order. If it is OK, click the Submit Order button. The "Clear Form" button will clear the data in the form making it blank again allowing you to retype the data needed into the form.

First Name: Middle Initial: Last Name: E-mail Addr: Company: Mailing Address: Address: Address: City: State: Zip Code: Country: Country Code: *Home Phone: Home Fax: Work Phone: Work Fax:

Please list below the sale or Special Offer # you are ordering from Example: PTS#77 or SPO#1 (SPO for special Offer). Please type as shown, not leaving a space between the sale (ex: PTS#)and the number(ex:80). I am Ordering from: Lot Numbers:

Comments:

Our Land Line # is:
870-376-4520

Our snail mail address is:
224 Turnberry Ct.
Mountain Home, AR.
72653-4179

Please check your order. If it is OK, click the Submit Order button.
The "Clear Form" button will clear the data in the form making it blank again allowing you to retype the data needed into the form.