|
Revised 8/2009 Source Code 09081101
Billing Address:
Name____________________________________
Company_________________________________
Address__________________________________
City______________ State___ Zip Code_______
Phone Number_____________________________
E-mail____________________________________
Shipping Address (if different than above):
Name____________________________________
Company_________________________________
Address__________________________________
City______________ State___ Zip Code_______
Phone Number_____________________________
E-mail____________________________________
Tax ID Number____________________________
Date_____________________________________ P.O.Number_______________________________
Bottle Stoppers (for quantities up to 96, call for prices on larger quantities)
Cork Stoppers Quantity @ $9/each Total $______
Chrome Stoppers Quantity @ $12/each Total $______
Cork & Chrome Stoppers Quantity @ $12/each Total $______
Clocks
4” by 4” Clock Assortment Quantity @ $12.50/each Total $______
5” by 5” Clock Assortment Quantity @ $16.50/each Total $______
Pendants
100% Millefiori
1” Round Millefiori Pendant Assortment Quantity @ $8/each Total $______
1” Square Millefiori Pendant Assortment Quantity @ $8/each Total $______
1” Heart Millefiori Pendant Assortment Quantity @ $9/each Total $______
1 1/2” Round Millefiori Pendant Assortment Quantity @ $9/each Total $______
Millefiori on Glass
1” Round Murano Pendant Assortment Quantity @ $8/each Total $______
1” Square Murano Pendant Assortment Quantity @ $8/each Total $______
1” Rectangle Murano Pendant Assortment Quantity @ $8/each Total $______
1” Round Murano Pendant Assortment Quantity @ $8/each Total $______
To select individual bottle stoppers, jewelry or clocks, use this chart.
| Item # |
Quantity |
Amount |
Item # |
Quantity |
Amount |
Item # |
Quantity |
Amount |
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
Total Amount |
|
Displays
Small Bottle Display (holds 13) Quantity________ @ $25/each Total $______
Large Bottle Display (holds 29) Quantity________ @ $37/each Total $______
Acrylic Display (holds 36) Quantity________ @ $35/each Total $______
Total Order before Shipping $__________
Shipping Method (billed at cost) ____Ground Shipping ____ Overnight ____ 2nd Day
Payment Method ____VISA ____MasterCard ____American Express ____Discover
Credit Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp. Date __ __/__ __
Signature__________________________________ Date__________
|
