Pay to order of / Mail to: Mary Law Goff Rt. 8, Box 840-3 Lake City, FL 32055 Phone: 904.961.9529, Fax: 904.719.8962

Name _________________________________________________________________

Address ______________________________________________________________

City __________________ State _________ Zip Code ___________-_________

Country ___________________ (Additional shipping charges if outside the U.S.)

Phone ____________________________ Email _____________________________

Item                                         Price

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9% shipping and handling charge ______________________________________

5% discount if money order or cashier's check payment ________________

                                            Total ___________________

Method of payment:

______Check    ______Cashier's Check    ______Money Order

______Credit Card    ______Visa    ______Mastercard

______Discover    ______American Express (15 day approval wait)

Credit card holder's name ____________________________________________

Credit card number _________________________________  Exp. ___________

                       Thank you for your order!