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phone: (336)859-0615
fax: (336)859-0658 email:
thomasvillecc@triad.rr.com mail: P.
O. Box 1148 Denton, NC 27239
Please print clearly. This form will fit on one page if
printed at 75% or 80%.
Please read, print and enclose a signed copy of the
terms.
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Item No. |
Description |
Price |
Wgt. |
Qty. |
Extended Price |
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Total |
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Method of Payment:
Shipping Address: Phone Number: Daytime________________
Evening__________________Email________________________
Special Instructions:
Check
Credit Card
Cashiers Check
Money Order
Credit Card Information:
Mastercard
Visa
American Express
Discover
Card Number: _______________________
Expiration Date: __________ Security Code: ______
(three digit number on the back of the card)
Name as it appears on your card:
__________________________________
Customer Name __________________________________________
Billing Address: (If different from Shipping Address)