ORDER FORM
Patchwork
Designs, Inc.
8421 Churchside Drive
Gainesville,VA
20155
703-743-9948 FAX: 703-743-9942
|
Name_____________________________________________________________________ Address___________________________________________________________________ City____________________________________ State_____________ Zip_____________ Phone ( )_____________________ Referred By:______________________________ Email Address: _________________________________________________________ Discover/Mastercard/Visa# _________-________-________- ________ or Check #_____ Expiration Date:_______________ Have you ordered before?__________________ |
|
Item
#
|
Description
|
Quantity
|
Unit
Price
|
Total
Price
|
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
|
SUBTOTAL
|
$ | |||
|
Regular
Shipping & Handling (view chart)
|
$ | |||
|
Special
Shipping (next day, priority mail etc)
|
$ | |||
|
TOTAL
ENCLOSED
|
$ | |||