Name:_______________________________________________

Address:_____________________________________________

City:__________________ State:__________ Zip:________

/tr>
Item #: Item Description Quantity: Price
      
       
    
     
       
       
       
  Total   
Shipping   
Tax (MI 6%)   
Total Enclosed   


Card Type16 Digit Card Number             Expiration Date
   
Verification Number (from back of card) 

Signature:________________________________________

Please make checks or money orders out to
Megan Bouchard

Print this form and mail it to the following address:
Megan Bouchard
P. O. Box 573
Hazel Park MI 48030-0573
If you wish, you can call us during business hours
(8:30 AM - 5:00 PM ET) at (248)543-2696.