|
Mail or Fax this completed form to:
Madonna Shops
1479 E. Foothill Blvd.
Upland, Ca. 91786-4054
Fax: 909-946-4216
Fax Toll Free: 888-453-7328
Payment Method:
__ Check/Money Order
__ MasterCard
__ Visa
__ Bill us, Churches only
|
Name
|
|
|
Billing Address
Address
|
|
|
City, State Zip
|
|
|
ship to Address
if different than above
Address
|
|
|
City, State Zip
|
|
|
e-mail Address
|
|
|
Phone Number
|
|
|
Credit Card Information
|
|
Fax Number
|
|
Name on Card
|
|
|
|
|
Card Number
|
|
|
|
|
Expiration Date
|
_____ / _____ Month / Year
|
|
Item Number
|
Description
|
Unit Cost
|
Quantity
|
Extended Cost
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sub Total
|
XXXXX
|
XXXXX
|
|
|
|
Shipping/Handling
|
XXXXX
|
XXXXX
|
|
|
|
Ca. Tax 7.75%
|
XXXXX
|
XXXXX
|
|
|
|
Total
|
XXXXX
|
XXXXX
|
|
|
SHIPPING/HANDLING charges
|
MINIMUM ORDER $50.00
$50.00 TO $99.99 ADD $6.00
OVER $100.00 ADD 5%
|
|
