Pipe
Squeez International
Ltd.
1 Willow Park Crescent
Glasnevin North
Dublin 11
Ireland.
FAX: +353-1-8643569
Phone +353-1-8429801
| Please fill in the form below to purchase your
Pipe Squeez by credit card. After your purchase has been approved, your order will be shipped. NOTE: Purchases can ONLY be made by the person named on the credit card. All orders will be shipped to address listed below. |
| Credit Card Number: | ________ ________ ________ ________ |
| Expires (mm/yy): | _____/_____ |
| Email Address: | ________________________________________ |
| Customer First Name: | ________________________________________ |
| Customer Last Name: | ________________________________________ |
| Phone Number: | ________________________________________ |
| Street Address Line 1: | ________________________________________ |
| Street Address Line 2: | ________________________________________ |
| City: | ________________________________________ |
| State or Province: | ________________________________________ |
| Zip or Postal Code: | ________________________________________ |
| Country: | ________________________________________ |
| Name of Person on Card: | ________________________________________ |
| Total amount: | ____________________ |
| Signature: | ____________________ |