U.S. Mail Order Form

You can use this form to order your sunglasses via mail. Please fill out this form completely and hit the submit button. Print the response page, sign and date the form, and add your credit card number (which you omit while filling out the form online). Once you have completed all of the above, please mail the form to My Sunglasses, P.O. Box 780161 Dallas, TX 75378. IMPORTANT: please make checks payable to PowComm. If you prefer, you can fax the order to 1-888-742-2532.
Note: your order cannot be processed until we receive your signed order confirmation form via fax.

Please provide the following billing/shipping information. For credit card security reasons, sunglasses can only be shipped to the billing address of the credit card.

      First name  Middle initial 
       Last name 
  Street address 
 Address (cont.) 
            City  State/Province 
 Zip/Postal code 
      Work Phone (ex xxx-xxx-xxxx)
      Home Phone (ex xxx-xxx-xxxx)
             FAX (optional)
          E-mail 
 Yes, Please send me special offers from My Sunglasses via email
 No Thank you, please do not send me special offers via email

Please provide the following ordering information:

QTY        Model(ex DR5460)      DESCRIPTION (ex Pandemonium Silver/Silver mirror)

Shipping Charges 1/$6.50 2/$7.75 3/$9.50  US Addresses Only
Texas Sales Tax 8.25% for all shipments to Texas addresses

Promotional Code

Total Charges due: $ Please Include Shipping and Applicable Taxes
Note: if your total is different from the actual amount due, we will notify you via email before processing the order.

3. Please Provide the following payment information:

    Payment Type 
 Cardholder name 
 Card number Fill in once you print form 
 Expiration date  (ex. 03/99)
 Issuing Bank     (ex. Citibank, MBNA, etc.)
 Credit card 800 Number 
 (bank information is used for fraud prevention checks)

I agree to pay for the above goods and services. I have read and agree to the terms and conditions regarding shipping and 30-day return policy. Note: the charges for this purchase will appear as "PowComm Internet Services" on your credit card statement.