Future
Heirlooms
Mail in Layaway order
form
Mail To: Future Heirlooms
Phone: (203) 389-7489
or Fax:
(203) 387- 8836
DATE:
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Bill To: |
Ship To: |
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Name |
Name |
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Company |
Company |
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Address |
Address |
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City, |
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Phone |
Phone |
Comments or Special Instructions: If there are any special instructions please include them in
the comment box.
Method of Payment: Personal Checks, Money Order or Credit Card VISA______ Master Card______ American Express______ Discover______
Card Number
____________________________
Exp. Date ____________ (Month/Year)
Code (3 #’s on
back) ___________
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QUANTITY |
DESCRIPTION |
UNIT PRICE |
AMOUNT |
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SUBTOTAL |
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Ct. SALES TAX |
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SHIPPING & HANDLING |
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TOTAL DUE |
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Make all money orders/Checks payable to: Future Heirlooms
If you have any questions, contact Gretchen Viglione at: (203) 389-7489 or
email us at gw@futureheirlooms.net
THANK YOU FOR YOUR BUSINESS!
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Comments: |