Ordered by: | Ship to: |
Name: | Name: |
Address: | Business Name: |
City: | Address: |
State, Zip: | City: |
Day Phone: | State, Zip: |
Fax number: | E-mail: |
If paying by credit card, please be sure that your name and address are exactly the same as your credit card billing statement |
Quantity | Description | Price Each | Total |
Merchandise Total | |||
Shipping & Handling (see below) | |||
WI
Sales Tax 5.5% (Wisconsin Residents Only!) |
Method of Payment | |||||
---|---|---|---|---|---|
Check _____ | Bank Check _____ | Money Order ____ | VISA ____ | MasterCard ___ | DiscoverCard ___ |
Card Number |
Exp. Date __ __ / __ __ CVC #(back of card) __ __ __
Signature(for credit card): _________________________________________________
$10.50 for 1-3 items $2.00 each additional item |
$32.00 for 1-3 items $2.00 each additional item |
$36.00 for 1-3 items $2.00 each additional item |