PLACE YOUR ORDER


Simply complete this form and send it by mail, Fax or E-mail. If you wish you may call with credit card information.
Date:
Purchase Order #:
Bill to:
*=Required		                                                           Credit Card Information:
Name *: Card Holder Name:
Address: Address:
Address 2: Address:
City: City:
State: State:
Zip: Zip:
Country: Country:
Phone: Phone:
Fax:
E-mail*: Visa     MasterCard
Discover Card    American Express
Expiration Date: Credit Card Number:
Payment Method: U.S.A. funds only
Money Order enclosed 
Check enclosed (make payable to Florencia Fiume, Inc
Credit Card (complete credit card information)

 Enter Notes or Comments:

Item

Qty

Color

 S M L XL

Price

Amount
1
2
3
4
5
6

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Barbara Koto
Designer Knitware., 501 Seventh Ave.  Suite#206, New York, NY !0018 - USA
phone: 212.997.7747  fax: 212.997.7744 

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