ORDER FORM
Patchwork
Designs, Inc.
8421 Churchside Drive
Gainesville,VA
20155
703-743-9948 FAX: 703-743-9942
NEW ADDRESS, PHONE AND FAX effective August 20, 2007
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Name_____________________________________________________________________ Address___________________________________________________________________ City____________________________________ State_____________ Zip_____________ Phone ( )_____________________ Referred By:______________________________ Email Address: _________________________________________________________ Discover/Mastercard/Visa# _________-________-________- ________ or Check #_____ Expiration Date:_______________ Have you ordered before?__________________ |
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Item
#
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Description
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Quantity
|
Unit
Price
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Total
Price
|
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
| $ | $ | |||
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SUBTOTAL
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$ | |||
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Regular
Shipping & Handling (view chart)
|
$ | |||
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Special
Shipping (next day, priority mail etc)
|
$ | |||
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TOTAL
ENCLOSED
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$ | |||