AUSTRALIAN GEMSTONES ORDER FORM
SECURE PURCHASE SITE
Pri
Prices shown in local currency as of April 2010 A.D. Subject to change without notice. Allow 2 -3 weeks for delivery.
CREDIT CARDS ONLY ACCEPTED
(not UK Bankers or Debit Card).
TO PURCHASE GEMSTONES
COMPLETE FORM BELOW.
THEN CLICK SUBMIT BUTTON AT END
.
1 Client Details
Date
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01
02
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2010
2011
2012
Title
-
Mr
Miss
Mrs
Ms
Dr
Rev
First Name
Surname
Company
Position
2 SHIPPING DETAILS
Address
Suburb
State
Country
Post Code
3 CONTACT DETAILS
Work Phone
Home Phone
Fax
Email
4 ORDER DETAILS
Click arrow to select gemstones from list.
Type
Qty
Size/Price
Pack & Post
Amethyst
-
Small Cluster - $5.00
Medium Cluster - $10.00
Large Cluster - $20.00
10% ot total value min.$5.00
Citrine
-
Small Cluster - $8.00
Medium Cluster - $8.00
Large Cluster - $15.00
Herkemer Diamonds
-
Small 0.5 to 1 cm - $20.00
Small 1 to 1.5 cm - $40.00
Quartz Clusters
-
A Grade - $30.00
B Grade - $15.00
Rainbow Rock
-
Small up to 3.5 cm - $5.00
Medium up to 4.5 cm - $10.00
Large up to 6 cm - $15.00
5 PAYMENT DETAILS
Value
Add Pack & Post. $5.00 min. or
10% of total valu
e:
Total Amt payable
Card Type
-
Visa
Mastercard
Card Number
Expiry
Month
/ Year
Name on Card
For security purposes, please turn your credit card over and copy .....
the last 3 digits
PURCHASE STATEMENT: Please supply the products I have selected above. For payment, I authorise you to debit the above credit card for the total amount. I understand I will be contacted by phone, fax or e-mail confirming order. Following confirmation, the goods will be shipped to me.
PLEASE RECHECK THAT ALL THE BOXES HAVE BEEN
FILLED IN
BEFORE YOU PROCESS YOUR ORDER THEN CLICK
