Coin Orders by fax

To place an order by fax; PLEASE print this page, fill out the entire page and fax to 573-392-7176. The fax machine is in a secure area of our business, and viewed only by the owners. This page may seem too specific, but it has been designed for our non-USA customers.

Company name (if applicable) ___________________________________________________________

First name or initial (required) ___________________________________________________________

Last name (required) _________________________________________________________________

Shipping address – building (if applicable) _________________________________________________

Shipping address – street (required) ______________________________________________________

Shipping address – city (required) _______________________________________________________

Shipping address – state, province, prefecture, etc. (required) __________________________________

Shipping address – country (required) ____________________________________________________

Shipping address – postal code (zip code in USA) (required) __________________________________

VISA or MasterCard number (we accept no other cards) (required) _____________________________

Expiration date of card (required) _______________________________________________________

Billing address for the card (required if different from shipping address) _________________________

Billing address second line (if needed) ___________________________________________________

Daytime telephone number (required for shipments outside the USA) ___________________________

E-mail address in case we need to contact you (required)______________________________________

The item(s) you are ordering, (please include item # and price) ___________________________________

________________________________________________________________________________