| Ordered by: | Ship to: |
| Name: | Name: |
| Address: | Business Name: |
| City: | Address: |
| State, Zip: | City: |
| Day Phone: | State, Zip: |
| Fax number: | E-mail: |
| If paying by credit card, please be sure that your name and address are exactly the same as your credit card billing statement | |
| Quantity | Description | Price Each | Total |
| Merchandise Total | |||
| Shipping & Handling (see below) | |||
| WI
Sales Tax 5.5% (Wisconsin Residents Only!) |
|||
| MN
Sales Tax 6.5% (Minnesota Residents Only!) |
|||
| TOTAL | |||
| Method of Payment | |||||
|---|---|---|---|---|---|
| Check _____ | Bank Check _____ | Money Order ____ | VISA ____ | MasterCard ___ | DiscoverCard ___ |
| Card Number |
Exp. Date __ __ - __ __ Signature(for credit card): _____________________________________
$7.50 for 1-3 items $1.00 each additional item | $9.00 for 1-3 items $1.00 each additional item | $12.00 for 1-3 items $1.00 each additional item |