| Name:_______________________ Email:_______________________ Company
(optional):____________ Address:_____________________
____________________________ City:________________________ State:_______________________ Country:_____________________ Zip:________________________ Phone:(____)
_____-_______ $1.50 shipping on 1st class mail
delivery (__) I am enclosing a check or money
order for $______
make all checks payable to Beverly Johnson.
(__)
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: ______________ |