| Item Name | Qty. | Size | Color | Amount |
| Name Address Date |
Order Sub Total: | |||
| Shipping & Handling: Product Total Shipping Charge up to $10.00 $2.00 $10.01 - $40.00 $3.00 $40.01 - $75.00 $5.00 $75.01 - $115.00 $6.00 $115.01 - $250.00 $8.00 $250.01 and up FREE SHIPPING |
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| Tax @ 6.75%: | ||||
| Order Total: | ||||