MARSHA AND JOHN'S PLACE
P.O. BOX 1154
DECATUR, IL 62525
(217) 865-2213
e-mail: marshaandjohnsplace@juno.com
www.marshaandjohnsplace.com
This is a printable order form for you to use. You may make a copy of this page to send by mail or fax.
PLEASE PRINT CLEARLY IN BLOCK LETTERS
NAME______________________________ DATE____/____/____
ADDRESS:______________________________________________
______________________________________________________
STATE:______________ ZIP__________
e-mail_____________
COUNTRY________________________
PAYMENT:Check____Money Order______
Visa__n/a_____-_______-______-_______ expiration_n/a___/____
Master Card__n/a_______-_______-________-_______
expiration _n/a_____/______
Signature_n/a______________________________
_____DESCRIPTION_______|QUANTITY|_PRICE___|__TOTAL__
_________________________|________|__________|_________
_________________________|________|__________|_________
_________________________|________|__________|_________
Shipping and handling |_________
Total |_________