Your Name: _______________________________________
Shop Name: _______________________________________
Address: __________________________________________
City: __________________State: _______Zip: __________
Phone: (____)__________________Date:________________
| QTY. | DESCRIPTION | PRICE EA. | TOTAL |
|
Items Total |
|
| Kansas Residents Add Sales Tax (Items Total multiply by 6.65%) | |
| Shipping/Handling within the Continental United States |
$ 6.95 |
| Residential Delivery Charge (add $1.00) | |
| C.O.D. (add $8.00) | |
| Total Amount |
Payment Method: ___Check/Money Order ___COD
___Visa: ___MasterCard ___AMEX
Name on Card______________________________________
Credit Card Number___________________________ Exp. Date: ___/___
