TASER® Order Form          
Full Name:
Ship to Address:
Address 2nd line (if needed):
City, State, Zip:
Home Phone:
Daytime Phone (if different):
E-mail Address (optional):
Ever Convicted of a Felony:   (Yes or No)
Driver's License Number:
License Expires on:
License State:
Date of Birth:
Social Security #:
Name as it appears on credit card:
Credit card address (if different):
City, State, Zip (if different):
MC, VISA, American Express or Discover:
Credit Card Number:
Expiration date:
3 Digit Bank Number on back:
Item(s) you wish to order:
Total $ Amount:

         Order by Fax: (Type or Print Legibly) Print Out Page & Send to Secure Fax # (702) 341-1652.

         Driver's License, Date of Birth and Social Security Number are required for M18 and M18L purchases.
         The C2 background check is done after receipt at a charge of $9.95, and an activation code is issued.