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Chris White

770 NW Don

Madras, OR 97741

EARRINGS ORDER FORM

To Order: Print and mail this form to the above address with payment. Please allow 6 to 8 weeks for delivery.

SHIP TO:

NAME: _____________________________________________________

ADDRESS: __________________________________________________

CITY: ______________________STATE: _______ ZIP: _____________

E-MAIL ADDRESS: ___________________________________________

Email address is for purposes of contacting you if there's a problem with the order.

ITEM / DESCRIPTION

QTY

UNIT PRICE

TOTAL

Jacobs Ladder Version 1

Bead colors 1 __________ 2__________

 

$ 6.00

 

Jacobs Ladder Version 2

Bead colors 1 __________ 2 __________

 

$ 6.00

 

Jacobs Ladder Version 3

Bead colors 1 __________ 2 __________

 

$ 6.00

 

Jacobs Ladder Version 4

Bead colors 1 _________ 2 ___________

 

$ 6.00

 

Heart

Bead color ______________

 

$ 6.00

 

Churn Dash Version 1

Bead colors 1 _________ 2 ________

3 _________

 

$ 6.00

 

Churn Dash Version 2

Bead colors 1 _________ 2 ________

3 _________

 

$ 6.00

 

Churn Dash Version 3

Bead colors 1 _________ 2 ________

3 _________

 

$ 6.00

 

Tree

Bead colors 1 _________ 2 ________ 3 _________

 

$ 6.00

 

Spinning Star Version 1

Bead colors 1 _________ 2 ________

3 _________

 

$ 6.00

 

Spinning Star Version 2

Bead colors 1 _________ 2 ________

3 _________

 

$ 6.00

 

Spinning Star Version 3

Bead colors 1 _________ 2 _________

3 ________

 

$ 6.00

 

Sunny Lanes Version 1

Bead colors 1 __________ 2 _________

3 ________ 4 ___________

 

$ 8.00

 

Sunny Lanes Version 2

Bead colors 1 _________ 2 _________

3 ________ 4 ___________

 

$ 8.00

 

Ohio Star Version 1

Bead colors 1 _________ 2 _________

3 ________

 

$ 8.00

 

Ohio Star Version 2

Bead colors 1 _________ 2 _________

3 ________

 

$ 8.00

 

Shoo Fly Version 1

Bead colors 1 _________ 2 _________

3 ________

 

$ 6.00

 

Shoo Fly Version 2

Bead colors 1 _________ 2 _________

3 ________

 

$ 6.00

 

Shoo Fly Version 3

Bead colors 1 _________ 2 _________

3 ________

 

$ 6.00

 

SUB - TOTAL

 

SHIPPING & HANDLING

 

TOTAL

 

PAYMENT METHOD: Money Order _____ Certified Check _____

SHIPPING AND HANDLING COSTS

$ 0.00 to $ 9.99

$ 2.00

$ 10.00 to $ 49.99

$ 5.00

$ 50.00 to $ 99.99

$ 10.00

$100.00 to $199.99

$ 15.00

$200.00 and over

$ 20.00

Gold ___, Silver ___,

Pierced ___, Clip on ____

If ordering more then one of each pair please list them by name with your choices below here or on the back of the order form.