Date: ____________________________

Sold To: ____________________________

____________________________

____________________________

Phone: ____________________________

Visa/Master Card # ___________________

Exp. Date: ___________________

Quantity

Description

Price

Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sub Total:

 

 

 

UPS: $6.00 for first stein, $2.00 each additional

 

 

 

Illinios State Sales Tax: 6 % for Ill. Residents

 

 

Total Amount Due:

 

 For Office Use Only

Date Shipped __________________ Zone ______________________ Lbs.______________