ISLAND SUPERMARKET
COCONUT DRIVE					Phone	011-501-226-2972 / 2973
SAN PEDRO, AMBERGRIS CAYE					FAX	011-501-226-2984
BELIZE
Date
To Be Completed By The Cardholder
Card Type (MC or VISA or AMEX)					Security Code
Card Number			-		-		-
Expiry Date
		MM				YYYY
Name of Cardholder
Billing Address
Address
Address (cont'd)
City
State or Province
Country
ZIP or Postal Code
Phone Number
E-Mail Address
Amount To Be Charged		(amount on invoice - this amount is only a deposit, unavailable items, market
		prices and special orders will affect the final total. A refund or charge will be
		applied according to the final invoice amount.)
US$
		Minimum order is $200 US
I acknowledge that I have authorized the above charges and that I have reviewed payment and cancellation
policies applicable to my order. (Orders cannot be completed without a faxed or scanned signature)
Cardholder Signature
Payment and Cancellation Policies:
All orders must be paid 48 hours prior to arrival, all orders are purchased 24 to 48 hours prior to arrival.
For orders cancelled within 48 hours of arrival there is a 30% re-stocking fee, for orders cancelled between 48
and 96 hours prior to arrival there is a 10% re-stocking fee, for orders cancelled 96 hours or more prior to arrival
there is a full refund of any charges.
PLEASE FAX A COPY OF THIS WITH YOUR ORDER TO: 011-501-226-2984
DATE: