Sifu Buck Sam Kong Online Order Form

Please print this page and clearly fill in all the appropriate spaces. Buck Sam Kong 1021 S. Brand Blvd. Suite 102 Glendale, CA 91205 Payment Method: To pay by credit card, call, fax or mail in this form. To pay by check, mail in this form enclosed with a check.   tel / fax: 818.244.8748

First Name __________________________________________ Last Name ___________________________________ Shipping Address __________________________________________________________________________________ City ___________________________________________________________ State __________ Zip _______________ Ph:______________________________________email:___________________________________________________

To pay by Credit Card: Please check one: Visa Mastercard Credit Card#:___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Exp. Date: ___ /___ /___ Item#:___________ Qty: _____ Descr: _____________________________________ Amount $: ___________ . _______ Item#:___________ Qty: _____ Descr: _____________________________________ Amount $: ___________ . _______ Item#:___________ Qty: _____ Descr: _____________________________________ Amount $: ___________ . _______ Item#:___________ Qty: _____ Descr: _____________________________________ Amount $: ___________ . _______ Item#:___________ Qty: _____ Descr: _____________________________________ Amount $: ___________ . _______ Item#:___________ Qty: _____ Descr: _____________________________________ Amount $: ___________ . _______ Item#:___________ Qty: _____ Descr: _____________________________________ Amount $: ___________ . _______ Shipping & Handling: Within U.S. : Add $ 6.50 per item International : Add $12.00 per item For large quantity order, please call for quotation. Sub Total: ___________ . _______ 9.75% Calif. Sales Tax: ___________ . _______ Shipping & Handling: ___________ . _______ Total Amount enclosed: ___________ . _______