Mail in your order
print out the following order
form and Mail it to:
Beverly Roberts
63 Columbus ave
Farmingville,
NY 11738 | Name:_______________________ Email:_______________________ Company
(optional):____________ Address:_____________________
____________________________ City:________________________ State:_______________________ Country:_____________________ Zip:________________________ Phone:(____)
_____-_______ (__) I am enclosing a check or money
order for $______
make all checks payable to Beverly Roberts. (__)
I want to charge this purchase to my credit card.
(__)VISA
(__)Mastercard
Card Number: __________________
Expiry Date:____________________ Signature:
______________________ I authorize Patriotic-Jewelry.com
to charge this amount: ______________ |