Fax/Mail Order Form

Fax to (386) 756-5585 or mail with:
Credit Card info, Cashier's Check, Money Order or personal check payable to:
HelmetsRus 1007 Palm View Drive South Daytona, FL 32119 USA

First Name_______________________ M.I.____ Last Name_______________________________

Address__________________________________________________________________________

Additional Address information _______________________________________________________

City________________________________________ State __________ Zip Code ______________

Phone __________________________________

Qty	Description	Code	Size	Price	Total









	Shipping/Handling add $9.95 per helmet (min)
	Total Order

Fill out the following if paying by credit card by mail or for Credit Card Authorization.
Circle Type of credit card: MasterCard Visa American Express

Card Number _____________________________________________ Exp Date _____________

Three or four digit security code on card _______________

Email Address or Fax Number for Order Confirmation ____________________________________

Print name on credit card ___________________________________________________________

Cardholder's Signature _________________________________________Date________________

Credit card 800-Number for international Authorization _____________________________________