Mail Order Form

Sold To:

Name:______________________________________ Address:____________________________________
City:_______________________ State:___________
Zip:______________
E-Mail:

Ship To:

Name:______________________________________ Address:____________________________________
City:_______________________ State:___________
Zip:______________
 
Quanty
Descripition
Price
Amount
1.        
2.        
3.        
4.        
5.        
6.        
7.        
8.        
9.        
10.        
 
 
Sub-Total
  
If a Texas resident please add Sales Tax     x.0825
 
Shipping Charges
 

 
Total
  
Payment by Check or Money Order
Payment by Credit Card (Provide Information below)       Master Card     Visa
        Exp. Date
(MM-YYYY) 		  -  


Credit Cardholder Name: (Please Print) ___________________________________________


Credit Cardholder Signature: ___________________________________________


Please mail a copy of this to:
John Brookshire
P.O. Box 28
Bedford, TX 76095

 Or Fax Us:
817-283-0820