Time Warner

"The Palace" Fax order form:

Credit card type: 	

Card Number: 

Expires: 

First name: 

Last name: 

Street address: 

City: 

State: 

Zip/Postal Code: 

Day Phone: 

Evening Phone: 

(if international - please include country code)

Internet E-Mail Address



Case sensitive? Lower.


FAX TO: 001-619-530-2225