The P. B. Helms Company - PO Box 508 - Maiden, NC 28650
NAME______________________________________________________________________
ADDRESS___________________________________________________________________
CITY_______________________________________________________________________
STATE_____________________ZIP________________________
TELEPHONE________________________EMAIL_________________________________________
|
ITEM NO.
|
DESCRIPTION
|
QTY
|
PRICE EACH
|
TOTAL
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
HANDLING CHARGE: $5.00 TOTAL:__________________________________
CARD #________________________________________________________________
EXP______________
PRINT NAME____________________________________________