Order Form
Please Complete and Print 2 Copies
Name *
Address 1*
Address 2*
City*
State / Prov.*
Zip/Postal *
Phone*
e-mail *
Contact method *
Copyright 2008-2011 White Smiles Superstore, Toronto, Ontario, Canada.
All rights reserved under both International and Pan American Copyright Conventions.
Billing Information:
Date
Item
1
2
3
4
5
Product Description
Product #
Quantity
Price
Total
Order Information:
Shipping
Grand Total
Taxes
Credit Card Information:
Credit Card Type:
Card Holder Name
Card Number:
Exp. Date:
Security Code
Signature:
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Please print 2 copies and mail 1 copy with payment to:
White Smiles Superstore - 65 Shuter Street - Unit 121 - Toronto, Ontario - M5B 1B2 - Canada
Name *
Address 1*
Address 2*
City*
State / Prov.*
Zip/Postal *
Ship to Same as Billing or:
Fax: 1.888.412.4385
