TELEPHONE ORDER FORM Date: Sales Associate

:

CARD HOLDER:

First Name

M.I.

Last Name

TYPE OF CHARGE (CIRCLE ONE): AMEX VISA MC

ACCOUNT NO.:

EXP. DATE:

3 OR 4 DIGIT SECURITY CODE

BILLING ADDRESS:

Street

City

State

Zip Code

Billing Telephone

SHIPPING ADDRESS (IF DIFFERENT FROM BILLING):

Street

Apt./Suite/Floor

City

State

Zip Code

Telephone

Business/Mobile Telephone

ITEM NO./SERIAL NO.

RETAIL PRICE $ $

NO REFUNDSALL SALES ARE FINAL

SALES TAX $ SHIPPING & INSURANCE $

SHIPPING OPTIONS: (CIRCLE ONE) WATCHES ONLY:
Next day AM Next day 2nd day (only Messenger (NYC only) if value declared is less than $15,000)

TOTAL $

OTHER:

Next day AM Next day Messenger (NYC only)

2nd day

3rd day

AUTHORIZED SIGNATURE ON CARD ABOVE

DATE OF CARDHOLDER'S AUTHORIZATION

STORE USE ONLY Date: Authorization No.:

L.N Z.C. S.A.

B.T. F.N 3.D.C.

Franck Muller Retail, Inc. 38 East 57th Street, New York, NY 10022

Tel: 212.355.3736 ● Fax: 212.355.8192

TELEPHONE ORDER FORM Date: Sales Associate:

CARD HOLDER:

First Name

M.I.

Last Name

TYPE OF CHARGE (CIRCLE ONE): AMEX VISA MC

ACCOUNT NO.:

EXP. DATE:

3 OR 4 DIGIT SECURITY CODE

BILLING ADDRESS:

Street

City

State

Zip Code

Billing Telephone

SHIPPING ADDRESS (IF DIFFERENT FROM BILLING):

Street

Apt./Suite/Floor

City

State

Zip Code

Telephone

Business/Mobile Telephone

ITEM NO./SERIAL NO.

RETAIL PRICE $ $

NO REFUNDSALL SALES ARE FINAL

SALES TAX $ SHIPPING & INSURANCE $

SHIPPING OPTIONS: (CIRCLE ONE) WATCHES ONLY:
Next day AM Next day 2nd day (only Messenger (NYC only) if value declared is less than $15,000)

TOTAL $

OTHER:

Next day AM Next day Messenger (NYC only)

2nd day

3rd day

AUTHORIZED SIGNATURE ON CARD ABOVE

DATE OF CARDHOLDER'S AUTHORIZATION

STORE USE ONLY Date: Authorization No.:

L.N Z.C. S.A.

B.T. F.N 3.D.C.

Franck Muller Retail, Inc. 38 East 57th Street, New York, NY 10022

Tel: 212.355.3736 ● Fax: 212.355.8192

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