Name________________________________________________ Phone________________
Street ____________________________City ___________________ State____ Zip _______
Tall Vase
Tall Fish Lip Vase
Lamp Base
Small Fish Lip Vase
Posey Vase
Powder Box
| Tall Vase # __________ | @ $325.00 each | __________ | Tall Fish Lip Vase # __________ | @ $325.00 each | __________ | Lamp Base # __________ | @ $325.00 each | __________ | Small Fish Lip Vase # __________ | @ $175.00 each | __________ | Posey Vase # __________ | @ $75.00 each | __________ | Powder Box # __________ | @ $115.00 each | __________ |
| Sub-Total | Shipping Charges | Sub-Total | __________ | $1.74 - 2.50 | $ .75 | 41/2% VA sales tax (if applicable) | __________ | $2.51 - 14.95 | $3.00 | Shipping (see chart at left) | __________ | $14.96 - 30.00 | $5.00 | Total (US $) | __________ | $30.01 - 65.00 | $8.00 | $65.01 - 100.00 | $10.00 | over $100.01 | 10% of Sub-Total |
| Circle Method of Payment | Name on Card ______________________________ |
| Card Number ______________________________ |
| Expiration Date __________ |
WebMaster: Wayne S. Orchard