secureform

Kentucky Barrels & Kentucky Rustic
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SECURE CREDIT CARD ORDER FORM

Use this secure form to email your Visa, Master Card, or Discover Card order
IMPORTANT! YOU MUST FILL OUT THE ENTIRE FORM

WE DO NOT ACCEPT AMERICAN EXPRESS

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:
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 & Kentucky Rustic - 6275 Hwy 2141 - Hustonville - KY - 40437
email: kybarrelquote@gmail.com <> phone: 606-282-0921