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 REFUNDS-
ALL SALES ARE FINAL SALES TAX $

SHIPPING & INSURANCE $

SHIPPING OPTIONS:
(CIRCLE ONE) TOTAL $

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

OTHER: Next day AM Next day 2nd day 3rd day

Messenger (NYC only)

AUTHORIZED SIGNATURE ON CARD ABOVE DATE OF CARDHOLDER'S AUTHORIZATION

STORE USE ONLY

Date: Authorization No.:

L.N B.T.
Z.C. F.N
S.A. 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 REFUNDS-
ALL SALES ARE FINAL SALES TAX $

SHIPPING & INSURANCE $

SHIPPING OPTIONS:
(CIRCLE ONE) TOTAL $

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

OTHER: Next day AM Next day 2nd day 3rd day

Messenger (NYC only)

AUTHORIZED SIGNATURE ON CARD ABOVE DATE OF CARDHOLDER'S AUTHORIZATION

STORE USE ONLY

Date: Authorization No.:

L.N B.T.
Z.C. F.N
S.A. 3.D.C.

Franck Muller Retail, Inc.

38 East 57th Street, New York, NY 10022
Tel: 212.355.3736 ● Fax: 212.355.8192