P.O. Box 5892 Toledo, OH 43613
Phone: (419)902-4181
Fax: (419)269-0869
| Name: | Ship To: |
| Address: | Name: |
| City/State/Zip: | Address: |
| Telephone: | City/State/Zip: |
|
ITEM NUMBER |
ITEM DESCRIPTION |
STYLE/SIZE/COLOR (IF THERE IS A CHOICE) |
PRICE |
HOW MANY |
TOTAL AMOUNT |
| INSTRUCTIONS: Fill in form completely. Double check order and amounts. | 1. Merchandise Sub Total | $ |
| Write clearly and accurately to ensure prompt delivery. | 2. Tax (OH Residents Only 7.25%) | $ |
| Be sure to indicate style, size, or color whenever there is a choice. | 3. Shipping (See Chart) | $ |
| Do we have your correct address? | 4. Total | $ |
( ) Check / Money Order Charge this order amt. to my ( )Mastercard ( )Visa ( ) Discover
ChrgCard No._______________________ExpDate____Signature___________________
| Shipping up to $9.99 $4.75 |
| from $10.00 to $14.99 $5.25 |
| from $15.00 to $19.99 $5.50 |
| from $20.00 to $24.99 $5.75 |
| from $25.00 to $29.99 $6.35 |
| from $30.00 to $34.99 $6.50 |
| from $35.00 to $39.99 $7.25 |
| from $40.00 to $44.99 $8.25 |
| from $45.00 to $49.99 $8.65 |
|
over $50.00 FREE |