FAX TO:647.258.1702
www.petempire.ca
1 Promenade Circle PO Box 914
Thornhill, Ontario
L4J 4P0
Canada
905.390.1846
Toll free in Canada or the U.S.A. 1.888.261.1605

Step 1: General Information
First Name: ____________________________________________________
Last Name: ____________________________________________________
Address 1: ____________________________________________________
Address 2: ____________________________________________________
Address 3: ____________________________________________________
Address 4: ____________________________________________________
Postal Code/Zip Code: ____________________________________________________
Country: ____________________________________________________
Telephone Number: ____________________________________________________
Fax Number: ____________________________________________________
Email Address: ____________________________________________________
 
Step 2: Currency Selection
Process My Order In: AMERICAN FUNDS (Visa only)     CANADIAN FUNDS
 
Step 3: Credit Card Information
Credit Card Type: VISA     MASTERCARD     AMERICAN EXPRESS     
DINER'S CLUB
Card Holder: ____________________________________________________
Card Number: ____________________________________________________
Expiration Date: ____________________________________________________
 
Step 4: Order Selections
Title: ___________________________________________________ Product #: ______ Qty: ______
Title: ___________________________________________________ Product #: ______ Qty: ______
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Title: ___________________________________________________ Product #: ______ Qty: ______
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Title: ___________________________________________________ Product #: ______ Qty: ______