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Please write in your
name & address below: |
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NAME |
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ADDRESS |
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CITY
STATE
ZIP |
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PHONE |
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E-MAIL ADDRESS |
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Ship to a different
address: |
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NAME |
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ADDRESS |
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CITY
STATE
ZIP |
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PHONE |
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E-MAIL ADDRESS |
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QTY. |
ITEM NO. |
NAME OF ITEM |
ITEM PRICE |
TOTAL |
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$9.99 & under |
$6.50 |
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$10.00 to $49.99 |
$10.50 |
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$50.00 to $99.99 |
$15.50 |
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$100.00 to $199.00 |
$20.50 |
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$200.00 & over |
$35.50 |
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MERCHANDISE TOTAL
__________ |
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SHIPPING CHARGES
__________ |
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*LESS GIFT
CERTIFICATE(S) __________ |
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SUB-TOTAL
__________ |
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7% TAX FL
RESIDENTS ONLY __________ |
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TOTAL
ENCLOSED __________ |
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| Payment Options:
Money Order or personal check (7 day hold on personal checks) payable to:
Terry Jacques, President |
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| *Please
enclose gift certificate(s) with your order form and remit to the
address above. |
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By signing below, I certify
that I have read and understand the company policy. |
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X
________________________________________ |
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Thank you for your order! |
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