Please print and fill out the following information and send payment and this form to:

Ship To:

Name_____________________________________________________________

Address___________________________________________________________

___________________________________________________________

City_________________________________State________Zip______________

E-mail Address_____________________________________________________

Phone Number_____________________________________________________

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

SHIPPING:_______________________
TOTAL WITH SHIPPING:_______________

SHIPPING COST
0.01 - 9.99 $3.00
$10.00 - 49.99 $6.00
$50.00 - 99.99 $8.00
$100.00 - 199.99 $9.00
$200.00 and over $11.00

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