A Very Special Collection

PRINT AND MAIL FORM

Print out order blank, complete form, and mail to:

A Very Special Collection
PO Box 2243
Yorktown, VA 23692

Fax or phone in completed order to: 757-867-7711

Name:	Date:
Address:	Phone:
City & State:	Zip:

Item#

Name

Quantity

Item Price

Extension

Shipping & handling:

$ .00 to $5.00 - $1.50
$5.01 to $10.00 - add $2.50
$10.01 to $30.00 - add $5.35
$30.01 to $50.00 - add $7.50
...... over $50.01 - add $10.00

Make checks payable to:
A Very Special Collection

For credit card payment:
Circle One:
Visa --- Master Card --- Discover

Account Number:

Expiration Date:

Signature:

Sub Total

Virginia residents add 5% sales tax.

Sales Tax

See chart to determine correct shipping

Shipping

All International orders, send e-mail for shipping rate

Total Due

THANK YOU!

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