BILL TO: SHIP TO: (if different)
Name: ___________________________________ Name: ____________________________________ Address: ___________________________________ Address: ____________________________________ ___________________________________ ____________________________________ ________________ ______ ___________ _________________ ______ ___________ city state zip city state zip Day phone: __________________________ Phone: __________________________ E-mail: __________________________ (Sorry, we can not ship to APO/FPO or PO Boxes.)
YOUR ORDER
Item Size Color Quantity Price/item Total _______________________________ _________ _______________ ________ __________ __________ _______________________________ _________ _______________ ________ __________ __________ _______________________________ _________ _______________ ________ __________ __________ _______________________________ _________ _______________ ________ __________ __________ _______________________________ _________ _______________ ________ __________ __________ _______________________________ _________ _______________ ________ __________ __________ Merchandise total: __________ Sales tax: 7% within Philadelphia, 6% in the rest of Pennsylvania: __________ (tax does not apply to food or clothing items) For Orders totaling: Standard Shipping: Standard shipping (see chart): __________ Up to $19.99 $4.75 Express shipping (see below): __________ $20.00 - $50.99 $6.75 $51.00 - $75.99 $10.00 $76.00 - 100.99 $13.00 $101.00 - $200.99 $16.00 $201.00 and up 10% of merchandise total For express shipping, add to the above $10 for each $50 of merchandise ordered. (Orders to Alaska, Hawaii or Puerto Rico require express shipping.)
PAYMENT
[ ] Enclosed is my check payable to The Black Cat Gift Shop. [ ] I wish to charge my: [ ] Visa [ ] Mastercard [ ] American Express [ ] Discover Credit Card charge in the amount of $____________ Credit Card number: _____________________________ Credit Card Expiration Date (MM/YY) ______/______ Signature (required for Credit Card): _________________________________________________
| Print and mail this form with payment to:
The Black Cat Gift Shop 3426 Sansom St. Philadelphia, PA 19104 |