| Name: | Date: |
| Shipping address:
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Billing address (if different):
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| Email: | Day phone: | Fax: |
| Payment by: [_]VISA [_]MasterCard [_]Discover [_]American Express [_]PayPal [_]Money order [_]Check (allow 2 weeks) |
| Credit Card# ______________________________________ Exp. Date:_______/_________ |
| Name on card: _____________________________________ Signature: ___________________________________ |
| Shipping Method: [ ]UPS Ground [ ]UPS 3-Day Select [ ]UPS 2nd day air [ ]UPS Next Day Air [ ]USPS Priority Mail [ ]UPS Express Canada [ ]UPS Expedited Canada [ ]UPS Standard Canada (ground service) [ ]Pick up at Keith's |
| Qty | Item # | Description | Cost ea. | Total |
|---|---|---|---|---|
| Product subtotal | ||||
| Actual shipping charge (will added by customer service)* | ||||
| Subtotal | ||||
| Pennsylvania residents add 6% sales tax | ||||
| Total | ||||
| *We use UPS or USPS actual shipping charges and e-mail you an order confirmation with shipping charge. |
| Keith Specialty Store, 6791 Route 119 Hwy N, Marion Center, PA 15759 fax: +1 724.397-2228 voice: +1 800.705-8838 |