SPADS - Flea Market Mall - Kiosk (Store) Order Form

Please complete the following, and press the Proceed button to start the Payment process.

9/7/2010SPADS - Flea Market Mall 
5500 So. SIMMS ST., pmb Suite 210, Littleton, CO. 80127
Office: (303) 697-4100 - Fax: (303) 697-4100

Days Description Cost Total
90 Days Flea Market Mall - Lease Payment $ 29.85 $ 29.85

If Renewal:   Enter Kiosk Number:   (leave blank if new account!)

CLIENT INFO:               ( All Fields Are Required - Except Fax )

First NameLast Name
Address
CityStateZip
Country
Day PhoneFax
E-mail

PAYMENT METHOD:    (The name you entered in above must match the Card or Account below)

 PAY PAL
 Use Pay Pal Payment Gateway Options!
There is no account required to pay at PayPal now!
You can pay with a Credit Card or your PayPal account!
It's Fast, Safe, and Secure to pay with PayPal!
Credit Card
If Credit Card is selected please also complete the Credit Card Information section to the right.
  (Do not include spaces)		 Credit Card Information
Card Name

Card Number:


Expiration Date: ( 09/09 )
/
CVV #: (last 3 or 4 digits
 - on back of card!)
Pay by Check
If Pay by Check is selected please see the Note to the right
 Note: If you do not wish to place your credit card information on this form, you can select the Pay by Check option, and when you receive your conformation Email Receipt,
you can either;
1. Fax your signed order to our office. (Fastest and most Secure)
2. Secure Email it back to us with your signed information.
3. Print out the Email Receipt and along with your payment, send it US Mail to us.

Fax Email Mail In
Please enter any comments you may have:

   

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