SmartHomeUSA Fax Order Form: Page 1 | 2
	To place your order via fax, fill out and print out both pages of this form and fax it to to us at 631-724-7145.
Shipping Address
First Name
Middle Name
Last Name
Address 1
Address 2
City
State / Province
Zip / Postal Code
Country
Phone
	Use this address also as the Billing Address
Billing Address
Company Name
First Name
Middle Name
Last Name
Address 1
Address 2
City
State / Province
Zip / Postal Code
Country
Phone
Order Payment Information
Card:	Discover Visa American Express Master Card
Credit Card #
Expiration Date
Cardholder's Name
Card Security Code	For security purposes, we require the Card Security Code on your credit card. For most credit cards, enter the three-digit number that follows your account number on the back of your card. If you have an American Express card, enter the four-digit number printed above your account number on the front of your card.