3723
Bay Road
Erie,
Michigan 48133
Phone:
(419) 304-1801 – (734) 723-7475
E-mail:
jachinger@aol.com
1.
Product Description________________________________________
2.
Product Number
________________________________________
3.
Size: (circle one of the following)
picture size |
fits frame size |
price |
|
5 by 7 |
8 by 10 |
$14.95 |
|
8 by 10 |
11 by 14 |
$19.95 |
|
11 by 14 |
16 by 20 |
$24.95 |
|
13 by 19 |
18 by 24 |
$29.95 |
|
4. Frame: (circle one of the
following – if desired)
frame size |
|
price |
|
8 by 10 |
|
$8.00 |
|
11 by 14 |
|
$10.00 |
|
16 by 20 |
|
$20.00 |
|
18 by 24 |
|
$25.00 |
|
Choose a frame color by placing a
checkmark next to
Color: Standard Oak ( );
Blue Metal ( ); Red Metal ( );
Silver Metal ( )
5. Decorative Matt: (circle
one – if desired)
matt for frame size |
|
price |
|
8 by 10 |
|
$2.00 |
|
11 by 14 |
|
$3.00 |
|
16 by 20 |
|
$4.00 |
|
18 by 24 |
|
$5.00 |
|
Choose a matt color by placing a
checkmark next to
Color: Charcoal ( );
Dark blue ( ); White ( ); Red ( ); Dark
Green ( );
Tan
( );
Light Blue ( ); Light Green ( ); Cream
( );
Gull Grey ( );
6.
Quantity ___________________________________________________
7.
Comments _________________________________________________
_________________________________________________
8.
Your Total: (total of all items – shipping
charges and sales tax are already included in all prices)
$___________ ._____
9.
Money Order / Official Bank Check Payment – Make
payable to:
10. Credit Card Payment: (circle
one of the following)
Master Card |
|
Visa |
|
Card Number
__ __ __ __
__ __ __ __ __
__ __ __ __ __
__ __
Expiration
Date: (circle the month and year)
January |
2004 |
|
February |
2005 |
|
March |
2006 |
|
April |
2007 |
|
May |
2008 |
|
June |
2009 |
|
July |
2010 |
|
August |
2011 |
|
September |
2012 |
|
October |
2013 |
|
November |
|
|
December |
|
|
Please Note: As an added
security measure, for your protection, we ask that you enter the last three
digits found in the signature block on the back of your credit card:
___ ___ ___
11.
Card Holder Name: ___________________________________________
Address:
___________________________________________________
City,
State, & Zip Code________________________________________
Name: _____________________________________________________
Address:
___________________________________________________
___________________________________________________________
City,
State, & Zip Code: _______________________________________