QuaggyBox- AG
247 SW 8th Street #459
Miami, FL 33130

Alexis Golden Mail Order Form

Item #


DVD Title or Clothing Item Description






Postage, Shipping and Handling Charges are $5.95 for the first Item and .75 cents for each additional Item

Make Check or Money Order Payable to: CASH, or leave Blank

CASH Purchases deduct an additional 10% from the Total

(Note: Cash is green money, NOT a check or money order)

Note: No orders will be shipped without a signature below!!!

I, the undersigned, hereby declare under penalty of perjury as follows:

Print your name: Your age: Today's date:

Please print clearly:

City: State: Zip:
Country: Telephone:
E-mail address:

Credit Card Information:  Visa, AMEX, Discover, MasterCard or JCB  (Circle One)

Card Number: ____________________________________

Expiration Date: _____________

NOTE: Your charge will appear on your statement as QuaggyBox

I no longer accept FAX Orders