MANUAL ORDER FORM

Please take a print out and complete this form, Fax/Mail it and order will be processed soon.

Samstores.com

Samstores
1500 Midway Ct
Suite W8
ELKGROVE Village, IL-60007
TEL- 847-290-1718 OR 847 290-1720.
FAX -773-4421566

Item No Item Description Qty. Unit Price Amount
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Grand Total $

Payment Information
Card Type ____________________________________
Card Number ____________________________________
CSC Number ___________

[The Card Security Code (CSC) is a 3- or 4-digit number printed in the signature field on the back of your credit card. On some cards, the credit card number, or part of it, appears before the CSC. The number appears only on the card itself (not on your receipts or statements). If your card has a CSC, enter it on the form.]
Expiration Date ____________________________________
Card Issuer (bank) Name & Phone No. ____________________________________

Card Holder Information or Billing Address

Salutation Mr. Ms. Mrs.
First Name _____________________________M.I.____
Last Name _____________________________________
Company Name _____________________________________
Address ____________________________________

[Address where credit card statements are received]
City ____________________________________
State/Province ________________Zip: _________-________
Country ____________________________________
Phone No ____________________________________

[For Security reasons, it may be necessary to contact you at this phone number before your order is shipped]
Email ____________________________________

Shipping Information

Salutation Mr. Ms. Mrs.
First Name _____________________________M.I.____
Last Name _____________________________________
Company Name _____________________________________
Address ____________________________________
City ____________________________________
State/Province ________________Zip: _________-________
Country ____________________________________
Phone No ____________________________________
Special Shipping Instructions ____________________________________
By providing above information, you authorize us to charge on your credit card for above purchase order

For all International orders, we require you to fax us at 773-442-1566 or email us at info@samstores.com the following:
  • A clear copy of the Front and back end of your credit card.
  • A clear copy of a Valid Driver license or State ID or Photo ID.