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.

Item No.

Description

Price

Wgt.

Qty.

Extended Price

           
           
           
           
           
           
           
           
           
           

Total

     

Method of Payment:   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 __________________________________________

Shipping Address:  
 





Billing Address: (If different from Shipping Address) 
 




Phone Number:  Daytime________________ Evening__________________Email________________________

              Special Instructions: