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Customer’s Name |
Phone
No. |
Date |
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Address
Apt. No. |
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City
State
Zip Code
Country |
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Cash |
Check |
Visa Master Card
American
Express Diner’s
Club Discover
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Account
No.
Exp. Date
Customer’s Signature ____ _______________________ |
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Quantity |
Description |
Price |
Amount |
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UP TO
$19.99 . . . . . . . . . . .
$6.00 $20.00 TO
$34.99 . . . . . .
$8.00 $35.00
TO
$39.99 . . . . . .
$10.00 $40.00
TO
$59.99 . . . . . .
$12.00 $60.00 TO
$79.99. . . . . .
$14.00 $80.00 TO
$124.99. . . . .
$16.00 $125.00 and up .
. . . . . . . . . .
$18.00 Next Day or Rush Orders please add $16.00 to order International Orders Add $10.00 International Rush Delivery Please Add $20.00 |
Please
send me ______ additional Order Blanks |
No Charge
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Merchandise Total |
$ |
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Shipping and Handling |
$ |
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Subtotal |
$ |
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WA State Residents please add applicable sales tax of 8.1% |
$ |
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Subtract any discounts, credits or certificates |
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Net Amount Due |
$ |
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