Order Form — L.A. Gold Leaf Wholesaler U.S.

Order Form

You can also use this form to place your order without using our online shopping cart.
Simply fill up this form, print and fax it over to 1 (626) 334-0502.
We will contact you within 24 hours after we receive this form or you can call us at 1 (626) 334-0470.

Contact Information

Full Name:

Telephone Number:

E-Mail Address:

Address:

City, State and Zip:

Shipping Information (leave blank if same as above)

Full Name:

Address:

City, State and Zip:

Order Information

Quantity	Product Model/Description	Price	Total










Shipping Method: USPS 2-3 Days Priority Mail USPS Express UPS

Sub-Total:

CA Sales Tax (9%):

Shipping Rate:

Shipping Insurance:

Total Due:

Name on Credit Card:

Credit Card Type:

Credit Card Number:

Expiration Date:

Comments

Prices subject to change without notice.