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Date:
Credit Card Type - Circle One
Ship to:
Visa, MasterCard, Discover
Address:
Card No.:
City/State:
Expiration Date:
Zip Code:
Signature:
Telephone:
Required for credit card orders
Paid by (circle one): Check Money
Order Credit Card
Do not send cash.
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Item Number |
Description (include size and color if
applicable) |
Quant. |
Unit Cost |
Total Cost |
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Shipping and Handling:
Priority Mail
Subtotal
US Canada
Up
$20.00
$6.25 $9.50
$20.01 to $49.99 $10.60 $15.00
$50.00 to $100.00 $11.00 $23.00
Over
$100.00 $15.00
$23.00
(Canada surface mail only) |
Subtotal |
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| IN residents 6% sales tax |
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| Shipping & Handling |
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| Total |
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Payable in US funds only -- No COD's
Mail Order to: Heirloom Corner
7872 N Troy Rd.
Greenfield, IN 46140
FAX: (317) 326-1915
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