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Padma Publishing Wholesale Order Form Date: _______________ Ordered by: Business Name: ____________________________________________________________________ Contact Person/Title: ________________________________________________________________ Reseller's Permit # (Required for U.S. orders): __________________________________________ Address: __________________________________________________________________________
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City ______________________________________________ State _______________ Zip/Postal Code _______________________ Country ______________________________ Telephone # ___________________________________________ Fax # (required for international orders ) ________________________________________ E-mail address (required for international orders) _________________________________
Ship to (if different from above): Business Name: __________________________________________________________________ Attn: ____________________________________________________________________________ Address:__________________________________________________________________________ _________________________________________________________________________________ City _______________________________________________ State _______________ Zip/Postal Code _______________________ Country ____________________________ VISA / MC / Discover card # ___________ - ___________ - __________ - ___________ Expiration Date _________ / __________ Security Code* (3 digits): ___ ___ ___ ___ Cardholder Name ___________________________________________________________ Credit card billing address (required): ____________________________________________________________ Signature __________________________________________________________________
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