secureform

SECURE CREDIT CARD ORDER FORM

Use this secure form to email your American Express, Visa, Master Card, or Discover Card order
IMPORTANT! YOU MUST FILL OUT THE ENTIRE FORM
We can't ship your order if we don't have ALL the information

IMPORTANT, YOUR ORDER IS A CONTRACT. READ OUR TERMS AND CONDITIONS BEFORE YOU PLACE AN ORDER

Please be sure you include the items you are ordering. Fill out the entire form

We use CryptoHeaven to encrypt this information, Click here to learn more about our SECURE ORDER FORM technology

* MAKE SURE YOU INCLUDE THE CVV2 NUMBER. WE NEED THIS NUMBER TO PROCESS YOUR ORDER
The CVV2/CID value is a 3 or 4 digit number printed on the credit card as shown in the illustration connected to this link CVV2

Billing Information (required)
First Name:
Last Name:
Company (optional):
Street Address:
Street Address (2):
City:
State:
Zip Code:
Phone:
Contact Email:

Credit Card (required)
Visa, MC, DC, AE:
Credit Card Number:
Expiration Date:	/
*INCLUDE THIS NUMBER CVV2:
CVV2 is a 3-digit number printed at the end of the credit card number on the signature panel on the back of the credit card
Ship To Address (If Different From Above)
Ship to Street Address:
Ship to Street Address (2):
Ship to City:
Ship to State:
Ship to Zip Code:

Items You Are Ordering (Please be sure to fill out this section)
Item Number & Total Ordered:
Item Number & Total Ordered:
Item Number & Total Ordered:
Item Number & Total Ordered:
Item Number & Total Ordered:

Kentucky Barrels - PO Box 1684 - Danville, KY 40423 <> email: kybarrels@windstream.net <> phone: 606-346-0887 <> fax 606-773-0401