Quick Piano credit card intake form
www.Homeschoolhowtos.com ~~~~~~~~ Phone: 970-385-1898

Purpose: This form enables users to make payment to Homeschool How-To’s (Cross-Over) by using a credit card (in person;
through the mail to Cross-Over, FLC 7028, 1000 Rim Drive, Durango, CO 81301-3999;
or by phone to 970-385-1809 ( but not by email, due to security considerations).

Name as printed on card: ____________________________________________

Billing address of card: __________________________________________________________

City, state, zip code: ___________________, ______ ______________

Phone number: (______) _______ - _______________

Type of credit card (circle one): MasterCard VISA

Credit card number: _______ - _______ - _______ - _______

Credit card expiration date: ____ / ____

3-digit security code from back of card: _______

Description of sale: ____________________________________________________________

Item numbers purchased (qty: 1 of each, unless otherwise noted): ____________________________________________
__________________________________________________________________________________________________

Products subtotal: $________ (see one-page order form)
Shipping charge: $________ (10% of product total, for shipping by Media Mail; no shipping charge for E-Books)
Handling charge: $________ ($1.00 or 3% of products subtotal, whichever amount is smaller)
Sales tax charge: $________ (2.9 % for orders coming from Colorado -- otherwise, no tax)
Total sale amount: $_______________

Today’s date: ________ _____, 200__

Customer’s signature: ___________________________________

Questions? send an email to crossover@ellison.net or call (970) 385-1809 (Monday-Friday)