Print
Mail or E-mail Order Form
Gallery Of Scentz
34 Burr Oak Street N.E.
Grand Rapids , Michigan 49505
Phone: (616) 365-0725
E-mail:
shall616@yahoo.com
(Copy
and paste to email your order or Print and mail order)
Customer Information
Name:_____________________________________________________________________________
Street
Address:_____________________________________________________________________________
City:
______________________________________ State:
________________Zip:______________________
Phone:
_____________________________________
Fax:____________________________________
E-mail:______________________________________________________________________________________
|
Item no.
|
Description Fragrance
|
Quantity |
Price Each
|
Amount |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
Sub-Total
|
|
|
| |
|
|
|
|
|
|
Shipping
Charges
(see
chart below)
|
|
|
| |
|
|
|
|
|
|
6% Tax for Michigan
Residents
|
|
|
| |
|
|
|
|
|
|
Total
|
|
|
Shipping Method
: First Class US Mail ______ International (Contact Company for
shipping cost)______
Credit Card
Information:
Visa ____ MasterCard ____ Name as it appears on card:
Credit Card Number:_____________________________________________________________________
Expiration Date: _____________________________________________________________________
All orders must
be prepaid
At this time we accept paypal payment, cashier's checks, money orders,
Visa, and MasterCard
Special
Instruction Notes:
|
|
|
Shipping cost is |
|
: |
| 1 Item
|
|
$2.00 |
| 2-3 Items |
|
$3.50 |
| 4-10
Items |
|
$4.50 |
|
11-20 Items |
|
$8.95 |
| All Item over 20 Contact Comapany For shipping
Cost |
|
|
|