| Payment Method Credit Card ___ Check ___ MO ___ | Total of Above Items | ||
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N.Y.S. Sales Tax is - 8% | ||
| Shipping & Handling | |||
| Order Total |
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Name (as it appears on the card if using a credit card): ______________________________________________ |
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| Address: _________________________________ City ______________ State _________ Zip Code ________ | ||||
| Phone No. (____)________________ E-mail Address ____________________ | ||||
| (Readings only) Date of Birth ________________ Time of Birth ________________ | ||||
| Ship Via: UPS US POST OFFICE - no c.o.d.s |
Extra charge for overnight |
Date: __________________ | ||
| Quantity | Stock # | Color | Size | Item Description | Unit Price | Total | ||
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| Payment Method Credit Card ___ Check ___ MO ___ | Total of Above Items | ||
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N.Y.S. Sales Tax is - 8% | ||
| Shipping & Handling | |||
| Order Total |
| Check Card type | MASTERCARD____ VISA____ DISCOVER____ AM. EXPRESS____ DINERS CLUB____ EXP. DATE - MONTH _____/ YEAR ____ |
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CHARGE CARD NUMBER |
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| ____ | ____ | ____ | ____ | - | ____ | ____ | ____ | ____ | - | ____ | ____ | ____ | ____ | - | ____ | ____ | ____ | ____ |
| Three digit # on back near your Signature ______ |
Billing Statement will indicate Golden Trines |
| Card Holder's Signature ___________________________________________ |
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