2 - THE ELECTRONICS STORE

Order Submission

* Indicates required field

Name *

First

Last

Address (Only collect the address if we are shipping an order to the customer) *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Has the customer paid for the item(s)? If not how much do they owe? *

Customer Pickup Location: *

Customer Requests: *

Items to Order: (Also include price) *

Submit