NAME_____________________________________________________________________

STREET ADDRESS___________________________________________________________

CITY______________________________STATE__________________ZIP______________

E-MAIL ADDRESS____________________________________________________________

HOME PHONE_______________________________________________________________
Can we contact you at this number if we have any questions? (yes / no)

ITEM & COLOR CHOICE_____________________________QTY______________________

ITEM & COLOR CHOICE_____________________________QTY______________________

ITEM & COLOR CHOICE_____________________________QTY______________________

ITEM & COLOR CHOICE_____________________________QTY______________________

                                                                                      TOTAL ORDER QTY.________

                                      SHIPPING ADD $7.95 (FREE IS ORDER IS OVER ________

                                     TOTAL $ AMOUNT OF CHECK/MO ENCLOSED_________
 

ADDITIONAL INFO:____________________________________________________

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