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Last Name First Middle Initial
USPS mailing
address:________________________________________________________________________
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USPS Shipping address (only if different from above):
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Your Telephone: REQUIRED (FOR CUSTOMS) OUTSIDE USA email
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Your Order: Quantity: Description: Price:
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WHERE DID YOU FIND US? Please be
specific._____________________________________________________
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Call or email for Shipping & Handling Charges. Must supply zip code__________________________
Visa ( ) Mastercard ( ) Check ( ) Money Order ( ) Pay Pal ( )
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Date:______________________
Charge Card No.
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name on card (Please print dark & clearly)
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Your signature+++ Thank you for your order! (Home)
DATE:
Pamela R. Martin
1848 Firetower Road
Prosperity, SC USA 29127