| To place an order print this form and mail it with your check, money order or credit card informationto the address at right. Please make checks payable to Jason Wallace. |
Jason Wallace 817 Mitch Circle Hudson, WI 54016 |
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QUANTITY |
DESCRIPTION (personalization or custom color if applicable) |
PRICE |
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| Item Subtotal | $ |
Wisconsin Residents Add Sales Tax: 5.5 % |
$ |
Shipping/Handling(USPS First Class): $0.00-$25.00 add $3.00 $25.01-$45.00 add $4.00 $45.01-$75.00 add $5.00 $75.01-$150.00 add $6.00 Over $150.00-FREE |
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TOTAL: |
$ |
Name: |
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Address: |
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City: |
State: | Zip Code: |
Email: |
Phone: | |
Payment Method(check one): ____Credit Card ______Personal Check _____Money Order
For Credit Orders(check one): VISA____ Mastercard____ American Express____ Discover____
Card #: ________________________________ Expiration:________ CVV2#(last 3 digits on signature strip): _______
Signature: __________________________________Date: _____________ Check here to be added to our mailing list:___