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Mail-in  or Fax Order Form
First Name __________________________   Shipping  Address ___________________
Last Name _________________________   _________________________________
Customer Number
( If Known) ____________________________________ 		  City           _________________________
E-Mail Address ________________________________ State _____________________________
Telephone Number _____________________________ Zip ______________________________
I am a New Customer
Yes
No
 
I certify that I am at least 21 years of age and there are no local, or state laws prohibiting me from purchasing or possessing ammunition, and I am under no legal disability as provided under18 U.S.C.992 (D) (1)-(7). Offer void where local or state ordinances prohibit the purchasing or possession of ammunition. I also understand that ammunition can be dangerous if misused or mishandled. It is unlawful for a person convicted of a "misdemeanor crime of domestic violence" to transport, possess, or receive firearms or ammunition.
I have read the above statement and agree that it is legal for me to order and possess ammunition.
Signature _____________________________   Date of Birth _____________
Description Item # Quantity Total Total Price
         
         
         
         
         
         
         
         
         
 
 
Sub - Total ___________  
Please Call For Shipping Cost
Shipping ___________  
Tax (If GA resident) ___________  
Total ___________  
Payment By: Card Number Expiration Date Security Code
on back of card
Visa
  
CCV #
Master card
  
CCV #
American Express
 
Last 4 
68
 
Mailing Check
Money Order		   Check # __________________  
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Billing Information
Name on Credit Card ___________________________
Credit Card Billing Address ___________________________  
Address line 2 ___________________________  
City ___________________________  
State ________________ Zip _______  
Name of Issuing Bank ____________________________________
You may fax your card number if you wish to (706) 867-8313
I will fax or call my card number in.
5
Do you want your Credit Card number saved? Yes
No
If you are mailing this information, mail to:
Gold City Gun & Cartridge Co. LLC
2112 Highway 19 North
Dahlonega, GA 30533
(706)864-1205
Fax (706) 867-8313