Ford's / Her Closet Order Form

Please provide the following contact information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Please provide the following ordering information:

Amount	Item Description or Product Code

Indiana Residence please add 5% sales tax to all orders

Shipping & Handling Chart

Purchase Amount

Add..

Up to $10.00	$1.95
$10.01 - $25.00	$4.95
$25.01 - $50.00	$6.95
$50.01 - $100.00	$8.95
$101.00 - $200.00	$10.95
$201.00 - $300.00	$12.95
$301.00 and over	$14.95

 

	BILLING
Credit Card	VISA MasterCard American Express Diner's Club Discover
Cardholder Name
Card Number
Expiration Date

If item is a present please provide the address to where the item is to be shipped, otherwise disregard below information request.

	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country