Date:
Email Address (If applicable):
First & Last Name:
Day & Evening Phone # (include area code):
Street Address:
City / State / Providence:
Country: Postal Code / Zip:

FORM OF PAYMENT:    _____Check     _____ Money Order    _____ Credit Card

Type of Credit Card (Visa or MasterCard):

Cardholder's Name:

Card # __________________________________________     Expiration Date:________
Card Holders Signature:

Qty

___

___

___

___

___

___

___

___

___

___

Item #

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

Product Name/Description

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________



*OH Residents add 5.5% sales tax


*PPD.  *Inquire for S&H to outside U.S.A.

Price

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

Sub Total

Sales Tax

Shipping

- TOTAL

Total Price

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

$_________

$_________

$_________

$_________

Mail to: Weathered Treasures
Jodi Pavlik
2504 Bazetta Rd
Warren OH 44481