Anything in Stained Glass Order Form

Fax Number: 1-800-231-5422

Name:   _____________________________________________
Address:_____________________________________________
Address:_____________________________________________
City:       _____________________State:______ Zip:_________
Phone:   ____________________________
Email:   _____________________________

Part Number	Qty.	Product Description	Unit Price	Total Price

Money Order #:	_______________
VISA/ MC/ Discover #:	_______________
Expiration Date of Card:	_______________
Signature:	_______________
Name on Credit Card:	_______________

Sub Total for Supplies:	_______________
Glass Box Charges:	_______________
Sub Total:	_______________
Under $25. Add $3.00 Handling	_______________
NJ Residents Add 7% Sales Tax:	_______________
Sub Total:	_______________
Less Gift Certificates:	_______________
Total:	_______________