Do not write in this space – (Office Use Only) Order ID: IS- (Please Use Dark Ink. No staples or tape on form)

Contact Information: Order Form Phone: Email :

* Enter Your Name & Shipping Address:

Mail Service: (Use Address Below) Send order form with payment to: Internet Smokes PO Box 40 Irving, NY 14081 Your Personal Check or Money Order Welcome

USPS Priority Mail Rates:
Up to 3 Cartons: $11.15 - 4 to 6 Cartons: $13.40 – 7 to 9 Cartons: $18.70
10 Cartons: $20.70 – Additional Add $2.00 Per Carton

BRAND	STYLE		QTY	PRICE	TOTAL
Special Instructions:		Fast and Fresh! Thank you		Sub Total	$
				Shipping - (See Above)	$
				TOTAL	$

1. Age Verification: (Required By Law): Existing Customers: Sign your name below.

New Customers: Sign your name below and send in a COPY of State issued ID (i.e. Drivers License)

I Certify that I and anyone I am ordering for are over my State’s Adult Legal Age: YES

___ Enclose Check or Money Order or

Enter Credit Card Information Below: We Accept: ___ MasterCard ___Visa ___Discover

____ ____ ____ ____ - ____ ____ ____ ____ - ____ ____ ____ ____ - ____ ____ ____ ____

Expiration Date: ____ / ____ Enter CVV (3 Digit Code) ____ ____ ___

I authorize you to charge my credit / debit card:

Sign Here: __________________________________________________________________

Visit us on the web: InternetSmokes.com