| Name: _________________________________________________ |
| Address: _______________________________________________ |
| City, State and Zip: _____________________ , ______ __________ |
| E-mail address: ____________________@____________________ |
| Phone#: _____-_____-________ |
| CREDIT CARD INFORMATION (if paying via credit card) |
| Card Type(circle one): VISA Mastercard |
| Name on Card: _________________________________________ |
| Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ |
| Security Code: __ __ __ Expiration: _____/________ |
| Product Description and/or ID Number | Quantity | Price Each | Total |
|---|---|---|---|
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| ******************(Attatch additional sheets if needed.)****************** | |||
| Shipping and Handling (Based on subtotal 1) | Totals | ||
| $10.00 and under.......$5.30 | Subtotal 1 | $ | |
| $10.01-$20.00.....$5.80 | Shipping & Handling | $ | |
| $20.01-$30.00.....$6.30 | Subtotal 2 | $ | |
| $30.01-$40.00.....$6.80 | 5.5% Tax (WI only) | $ | |
| $40.01-$50.00.....$7.30 | ---------------- | ||
| $50.01 or more....15% of Subtotal 2 | TOTAL | $ | |