Date: ___________
| Please enter the information in the spaces provided below | |
| Your Name | |
| Credit Card Number (Visa/Discover/Mastercard) |
|
| Expiration Date | |
| Address Card Bills to: (We call the bank to verify this for your security and product is normally shipped to the same address!) |
|
| Name of the Card Issuing Bank and Telephone
number (usually on the back of card) |
|
| Your daytime telephone number: | |
| Your evening telephone number: | |
| Your E-mail address: | |
| Your Fax Number: |
Item Number |
|
Size | Quantity | Price | Total Purchase |
|
| 1 | ||||||
| 2 | ||||||
| 3 | ||||||
| 4 | ||||||
| 5 | ||||||
| 6 | ||||||
| 7 | ||||||
| 8 | ||||||
| Total Order: |
Total Purchase |
UPS Ground |
UPS Second Day |
UPS Next Day |
US Postal Insured
|
| $0 - $50 | $ 6.00 | $14.00 | $24.00 | $10.00 |
| $50.01 - $100.00 | $ 8.00 | $18.00 | $30.00 | $12.00 |
| $100.01-$150.00 | $10.00 | $22.00 | $40.00 | $15.00 |
| $150.00 up | $12.00 | $25.00 | $50.00 | $18.00 |