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Print & Fax Order Form
| Name: ____________________________________ | E-mail:___________________________________ |
| Shipping Address: | Credit Card Billing Address: |
| __________________________________________ | ________________________________________ |
| __________________________________________ | ________________________________________ |
| __________________________________________ | ________________________________________ |
| MC/VISA #:________________________________ | Expiration date: ______________ |
| Qty | Style # | Description | Price | Qty x Price |
| Fax to:
(215) 344-4437 |
Order Subtotal |
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Shipping* |
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Insurance (optional)** |
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TOTAL DUE |
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*Shipping=$2.00/$10.00
$3.00/$50.00 $4.00/$100.00
$5.00/$200.00 $6.00/$300.00
(outside of the USA add $1.00 additional shipping)
** Insurance=$1.30/$50.00 $2.20/$100.00
$3.20/$200.00 $4.20/$300.00
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