ORDER FORM
(For quickest delivery pay by Credit Card)
Before filling out this form, please read our Terms of Sale
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First Name:________________________ Last Name:________________________________
Street Address:_______________________________________________________________
City:_________________________ State:________________________ Zip:______________
Daytime Phone Number:(_______)____________-___________________________________
Fax Number:(_______)____________-_____________________________________________
Email Address:________________________________________________________________
If paying by credit card, please complete the following:
____Visa
____Master Card
____American Express
____Discover
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Name On Card:__________________________________________
Credit Card Number:______________________________________
Expiration Date:__________________________________________
Authorized Signature:_____________________________________
Today's Date:____________________________________________
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[Please note: Coins must be shipped to the card holder's billing address.]
If paying by check or money order, please remit to:
Bedrock Gold & Silver, Inc.
P.O. Box 1987
Sisters, OR 97759
Phone: 800-32-COINS
(800-322-6467)
Fax: 541.549.1820
Please provide the following information about the item(s) you wish to purchase:
Title/Description:_______________________________________________________________
Grading Service/Grade:__________________________________________________________
Price:________________________________________________________________________
Please fill out this form completely and fax it to our 24 hour fax line.
Or, if you'd prefer, you can mail it to the above address.
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