Credit card order Form by FAX or Mail

Omni Systems Int'l Inc.

70 Yorkville Ave. #A-1  Toronto, Ontario,  M5R 1B9   CANADA

  • First, fill out this form with all required information and then use your browser's print button to print it.

  • Sign this form

  • Make a photocopy of front and back of your credit card

  • Make a photocopy of a signature ID card

  • Make a photocopy of the first page of your most recent credit card statement

  • Fax above to 416-975-0816, If you have trouble sending this form through fax please call us at: 416-816-3235

  • List of products on your order
  • Subtotal:
 in US Dollars
  • Shipping Cost:
 in US Dollars
  • Total:
 in US Dollars
  • Name as on Credit Card
  • Your Complete Billing Address of the Card including :
    city, state, country, postal code  ( where you receive your statements)
  • Phone No. of above address
  • Name of the person or company receiving the product
  • Your Complete Shipping Address including:
    city, state, country, postal code ( where you would like the product to be shipped to )
  • Phone No. of shipping address
  • E-Mail address for Replies if any

  • Type of Credit Card

  • Credit Card Number
Expiration Date (mo./yr.) 
  • Today's Date
 (mo./day/yr)
By Signing this form I Authorize Omni Systems Int'l to debit my account for the purpose of purchasing the items listed on this form for the total amount shown, also authorizing Omni Systems to ship and deliver the purchased products to the delivery address shown.

Card Holder Signature:

If you have trouble sending this form through fax please email : mailto:sales@closeouttrading.com  or call us at: 416-816-3235