Handy Dandy Fax or Mail Form

Thank you for your MouseBurger order! Print and fax or mail the completed form to:
United Pacific Corporation, 245 Roosevelt Road, West Chicago, IL, 60185
Attn: Headchef, FAX: (630)231-2888

Here's my Order! I'll take my MouseBurger to go!

NAME	        :_________________________________________________________

COMPANY NAME	:_________________________________________________________

EMAIL ADDRESS	:_________________________________________________________

STREET ADDRESS1	:_________________________________________________________

STREET ADDRESS2	:_________________________________________________________

CITY 		:____________________________  STATE:_____  ZIP:__________

PHONE NUMBER	:______________________   FAX NUMBER:_____________________


ALTERNATE SHIPPING ADDRESS

NAME	        :_________________________________________________________

COMPANY NAME	:_________________________________________________________

STREET ADDRESS1	:_________________________________________________________

STREET ADDRESS2	:_________________________________________________________

CITY 		:____________________________  STATE:_____  ZIP:__________

PHONE NUMBER	:______________________ (OF SHIPMENT DESTINATION)


QUANTITY (maximum of 2)		: ________ at $25.00 each

SHIPPING & HANDLING CHARGES	: ________ (see our Cost Calculator)


CREDIT CARD INFORMATION (PLEASE FILL IN ALL AREAS)

NAME ON CARD	:_________________________________________________________

CARD NUMBER	:____________________________________ EXP DATE:_____/_____

SIGNATURE	:_________________________________________________________

PLEASE MARK YOUR CARD TYPE     : VISA ____                MASTERCARD _____