ALPHA TOBACCO ORDER FORM
Please Print out this form and send it by mail or by fax

Name:
Address:
City:	Province/ State:
Postal / Zip Code:	Country:
Day Phone: ( )	Fax: ( )
Email:
Payment by: Visa MasterCard Money Order
Visa / MasterCard #:	Expiry: ____ / ______
I am over 19 years of age ................................Signature:
Shipment Address:
Item (s) Quantity Price in CAD Dollars Total in CAD Dollars                                         Sub Total $ Shipping $ 20.00 Total in CAD Dollars $

Fax to: (604) 944-1302

or

Mail to:
ALPHA TOBACCO, House of Cigars
829 Denman St.
Vancouver, B.C.
Canada V6G 2L7