Printable Order Form

Name
Street Address
City
State
Zip Code
Phone
E-mail
Payment Method
Card Number
Expiration Date	Month   Year
Requested Ship Date
Shipping Address	(If different from above):
Name
Street Address
City
State
Zip Code

Qty	Description	Price	Total
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
		$4.75
	Plant Total	$
	Handling	$	10.00
	Subtotal	$
	Sales Tax (MI residents 6%)	$
	Gift Certificate Number Amount Redeemed	-$
	Grand Total	$