| Name:_______________________ Email:_______________________ Company
(optional):____________ Address:_____________________
____________________________ City:________________________ State:_______________________ Country:_____________________ Zip:________________________ Phone:(____)
_____-_______ $1.50 shipping on all orders (__)
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: ______________ |