Order Form

We are not an e-commerce website.

Once you find the products you wish to purchase, either fill in the

form on-screen and print it off or print off our order form then fill it out.

Then, call us to place your order or send it to us.

We take VISA, MasterCard, & Discover, money orders and checks (2 week delay)

Please feel free to call us if you prefer to ask us for advice before placing an order.

Click Here for our Policies on: Returns - Freight Damage - Warranty


Date: 

 

Step 1

   Ship To:

Name:

 

UPS Delivery Address:

 

Mailing Address (if different):

 

City:

 

State:

 

Zip Code:

 

Phone Number:

 

E-Mail Address:

 

How Did You Hear About Us?

 

Do you need a new catalog?

  Yes     No

Step 1.5 (if needed)

   Bill To:

Name:

 

Mailing Address (if different):

 

City:

 

State:

 

Zip Code:

 

Phone Number:

 

Step 2

   Method of Payment:

         Please Check One

Check:

    Check Number:

Money Order:

     Money Order Number:

   Credit Card

   

Visa:

   

MasterCard:

   

Discover:

   

Card Number:

 

Expiration Date:

  Month -     Year -

3 Digit V Number (required):

  (Last 3 digits on reverse side of card)

Cardholder's Name (as it appears on card):

 

Step 3

   Your Order:

Qty. Item Number Item Description Price Each Total Price
 

Total

2.9% Sales Tax (CO Residents Only)
Sub Total
  See Below For Shipping Charges    Shipping Cost
Sub Total
2% Handling/Insurance
Total Due

Step 4

   Shipping Charges

Minimum Shipping

Order Total $100.01 - $200.00

Order Total $200.01 - $300.00

Order Total $300.01+

$10.00

10%

8%

6%

Call for possible lower shipping rates

   

All done?  Thank you for your order!

All Prices Are Subject to Change


Self Reliance Resources, P.O. Box 392, Burlington, CO  80807

Phone: (719) 346-4663  -  9AM-6PM Fax: (719) 346-4663  -  Hours: 9AM-5PM (MT) Mon.-Fri.

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