Bank wire request

Please fill out this form if you would like to purchase an item by bank wire. Once we receive your request, we will be happy to send you the information needed to begin the simple process. Thank you!

Item you would like to purchase:

Listed Price on Cushion Gem:

Your Name:

First Name

Last Name

Email Address:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

Country

(###)

###

####

Your Bank Name:

Date you would like to take delivery:

YYYY

Message or special instructions: