|
ITEM #
|
PRODUCT NAME
|
PRICE
|
QTY
|
ITEM TOTAL
|
|---|---|---|---|---|
| ________________ | __________________________ | __________ | ______ | _____________ |
| ________________ | __________________________ | __________ | ______ | _____________ |
| ________________ | __________________________ | __________ | ______ | _____________ |
| ________________ | __________________________ | __________ | ______ | _____________ |
| ________________ | __________________________ | __________ | ______ | _____________ |
| ________________ | __________________________ | __________ | ______ | _____________ |
| ________________ | __________________________ | __________ | ______ | _____________ |
| SUBTOTAL: | _____________ | |||
| TAX: Maryland ONLY Add 5% | _____________ | |||
| GRAND TOTAL: | _____________ | |||
|
BILLING INFO * Required Fields |
|
| *Billing First Name | __________________________ |
| *Billing Last Name | __________________________ |
| Company Name | __________________________ |
| *Billing Address | __________________________ |
| Billing Address2 | __________________________ |
| *City | __________________________ |
| *State | __________________________ |
| *Zip code | ____________ |
| *E-mail Address | __________________________ |
| *Phone Number (xxx-xxx-xxxx) | __________________________ |
| *Credit Card Type (visa, mastercard, discover, american express) | __________________________ |
| *Card Number (No dashes) | ____________ |
| *Expiration Date (mmyy) | ____________ |
| *Card Validation (CVV2/CVC2) Whats This? | ____________ |
|
SHIPPING INFO |
|
| * Shipping First Name | __________________________ |
| * Shipping Last Name | __________________________ |
| Shipping Company | __________________________ |
| * Shipping Address | __________________________ |
| Shipping Address2 | __________________________ |
| * City | __________________________ |
| * State | __________________________ |
| * Zip Code | ____________ |
| Mail Check Orders to: | Fax Credit Card Orders to: | ||
| Futon Furniture and more 7540-B Washington Blvd. Elkridge, MD 21075 |
1-410-799-1703
|
||