Order Form

Diversified Financial Group
PO Box 14
Mount Pleasant, SC 29465-0014

843-884-9851 / fax: 530-325-3924

http://www.4internetmarketing.net

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Billing Information
*Full Name:
Company:
*Day Phone:
Home Phone:
Fax:
*Email:
*Address1:
Address2:
*City:
*State/Province/County:
*Postcode/Zip:
*Country:
Where did you hear about us?
*Indicates a REQUIRED FIELD

Ship To Information
Please LEAVE BLANK unless different from address above.
Ship To Name:
Ship To Address1:
Address2:
City:
State:
Postcode/Zip:
Country:

Credit Card Payment Information
Name on Card:
Card Type:
Card Number:
Expire Date:		Month: Year:

Online Check Payment Information
Bank Name:
Bank Phone:
Bank Address:
Bank City:
Bank State:
Bank Zip:
Name on Account:
Account Number:
Transit Number:
9 Digit Routing Number:
Check Number:

Qty	Description	Total
	Mail Order in the Internet Age (19.95 with 5.00 shipping added)	$
Product Total		$
Enter Tax Rate % Taxes		$
Grand Total		$

Comments/Questions/Special Delivery Information
I authorize Diversified Financial Group Inc to charge me for the above total. I further affirm that the name and personal information provided on this form are true and correct. I further declare that I have read, understand and accept Diversified Financial Group Inc's business terms as published on the web site. Signature:

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