Order Registration Form

This form is to register you for our on-line purchasing. Your information is strictly for use by WALSER'S and will not be given out to anyone else for any purpose. Our order forms use e-mail processing and a secure web site server. A customer code will be assigned to you via e-mail following your initial registration. This form may also be faxed to us at (310)-891-3403.

Please note that for orders outside of the United States, we can only process payments with American Express credit cards or money wire transfers. No other credit cards allow account verification outside of the United States at this time and therefore they are not acceptable.

Before processing any order, we verify complete billing name and address for security purposes. Therefore, be sure that  your information below matches exactly as shown on your billing statement.

When placing orders on our product pages, enter the order quantities next to each product you wish to purchase. Enter your Customer Code and e-mail address at the bottom of the page you are ordering from. Then submit each page by clicking the bottom "Submit Order" button.

If you are altering previously submitted information or already have a customer code assigned from either our e-mail or order registration, please insert your assigned customer code here:

Customer Information Section

BILLING INFORMATION (as appears on credit card statement)
Company Name (if on credit card)
First Name (as it appears on credit card)
Middle Initial (as it appears on credit card)
Last Name (as it appears on credit card)
Credit Card Type
Account Number
Expiration Date (month) (year)

Credit Card CVV2 or CID Code Number (required)*
Street Address (required)
Address (cont.)
City (required)
State / Province (required)
Zip / Postal Code (required)
Country (required)

* The CVV2 or CID code number for VISA, MasterCard and Discover is the last three digits of the printed number on the back of your credit card in the signature area. The CID code number for American Express is the printed four digit number located on the front of the card above or below the account number's first four digits.

Telephone (required)
Additional Telephone
FAX Number

 

E-mail Address (required)
Additional E-mail Address

 

SHIPPING INFORMATION (if different from billing address)
Name
Company Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

NOTE: If you change your shipping address or credit card information, it is necessary to complete another registration form to update your information.

If you wish to receive notifications of special sales and new products, you must also complete our E-Mail Registration Form.

Additional Shipping Information:

 

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