Seneca Smoke Shop discount tobacco, cigarettes, cigars salesFAX Form

To order by FAX, print this form, complete and FAX to close this page
Seneca Smokeshop PO Box 25 Gowanda, NY 14070 Phone Orders: (877)766-5360 Fax: (716)549-8666 sales@senecasmokeshop.com
Offer limited to smokers age 21 or older. A four carton minimum of which can be of four different brands/flavors/items. Checks/money orders must include a copy of a government issued ID, usually a driver’s license and signature. Shipping and billing address must match. Expect package to be shipped within 3-5 business days of credit verification.
Name: _____________________________________________
Street 1: _____________________________________________
Street 2: _____________________________________________
City: _____________________________________________
State: _____ Zip: ___________
Phone: ______________________ please include area code
Email: ______________________________________________

Bank Name: __________________________________
Routing Number (9 Digits):_______________________
Account Number:______________________________
Check Number:________________________________
Driver License Number:__________________________

Item Description	Price Per Carton	Quantity	Total
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		Subtotal	_________
Shipping Charges: Your Shipping Information here.		Shipping:	_________
		Total:	_________
I HEREBY AUTHORIZE Seneca Smokeshop to electronically debit my account in the amount stated for payment. I also understand and agree that if the payment is returned due to insufficient funds, I will pay the original amount and a non-sufficient fund return fee of $40.00 or the maximum allowed by law. ________________________________________ Signature Date
Signature______________________________________________

Signature______________________________________________