Order Form

Browse through our pages:

Last
Name:

First
Name:

Middle
Initial:

Address:

Cty/St/Zip:

Country:

Phone:

Fax:

Email:

II. Ordering Information

Product Description	Qty	Unit Price

III. Shipping & Handling Information

If your order is:
up to $14.99........................add $1.50
from $15.00 to $19.99.........add $2.00
from $20.00 to $24.99.........add $2.50
from $25.00 to $29.99.........add $3.00
from $30.00 to $34.99.........add $3.50
from $35.00 to $39.99.........add $4.00
from $40.00 to $44.99.........add $4.50
from $45.00 to $49.99.........add $5.00
over $50.00..................... ...add $5.50

IV. Billing Information

Type of Payment :

V. Shipping Information

Please specify if shipping address is different than above.

Shipping Address:
City: State: Zip: Country:

Thank you for visiting the Purple Pansy.
Your order will be processed by pressing SUBMIT below.
Come again!

[1][2] [3] [4] [5] [6] [7] [8]

[Links] [Email]