Partner Order Form — Home Reserve Partnership Program

Please provide your order and credit card information below. By completing and submitting this form, you agree to provide the content outlined in your agreement by the agreed-upon deadline, or your credit card will be charged for your order.

Furniture Selection

Arm style, units, fabric selection

Name

BE SURE THIS NAME MATCHES THE NAME ON YOUR W9 FORM

First Name

Last Name

Email

Phone

(###)

###

####

Credit Card Number

Exp. Date

CVC

Code on the back of your card

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address

If different from Billing Address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country