Submit Order Manually

PLEASE ENTER BILLING & SHIPPING INFORMATION Enter your billing, shipping and payment information below. The billing information you provide must match the address to which monthly credit card statements are sent. Please Type in the ITEM Code(s) and/or ITEM Name(s) below Please verify the list of items provided below as they may not be exactly what was ordered. Manually type the names of any items which may be missing. Please enter your product codes here or item names and item prices!!!!! You can find them on your failed Checkout form by clicking back on your browser. Billing Address:

Name:
Address:
City:
State:
Zip/Postal Code:
Country:
Phone Number:
E-mail Address:	You will be e-mailed with a confirmation upon shipping.
Shipping Address:

Name:
Address:
City:
State:
Zip/Postal Code:
Country:
Shipping Method:





Payment Method:



Credit Card No.: Expiration Date: CVV2 Number: last 3-4 digits on back of card. All Credit Cards billed under "Mallcom Corp."

No Box Covers Necessary I certify that I am at least 18 years of age. I also certify that it is Legal to purchase and Receive these items in my County or State. It is legal for someone of my age to purchase and Receive these Items in my Country. I also certify that I read and agreed with ALL the FAQ/Terms & Conditions before placing this order. This box must be checked before the order can be processed.

You may also print this form and mail it along with a check or money order (in U.S funds) to:

Mallcom Corp.
55 Sea Cliff Ave.
Glen Cove, NY 11542
U. S. A.