Billing Name and Address

Shipping Address (if Different)

_{First Name             MI           Last Name}      

_{Address                               Bldg/Apt#}          

_{City               State                 Zip Code}         

_{First Name          MI                 Last Name}     

_{Address                                      Bldg/Apt#}      

_{City                    State               Zip Code}         

Item#

Item Name

Color/Style

Unit Price

Quantity

Total

Shipping Costs

UP TO $24.99 - $4.95   $25.00 to $49.99 - $7.95   $50.00 to $99.99 - $10.95

$100.00 to $149.99 - $13.95   $150.00 to $199.99 - $19.95

 $200.00 to$299.99 - $24.95  $300.00 to $399.00 - $29.95 

$400.00 to $499.99 - $33.95   OVER $500 - $38.95

TOTAL