539 Taylor Street #B , Mineral Wells, Texas 76067
855-MA-DEUCE
Customers desiring to place an order should use this printable form.
Completed order forms should be submitted by mail to the address above.
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QTY
|
SKU
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ITEM
DESCRIPTION
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PRICE
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TOTAL
|
| $ | $ | |||
| Subtotal : | $ | |||
| Shipping Charges : | ||||
| Sales Tax (TX Residents add 8.025%) : | ||||
| Total : | $ | |||
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BILLING
& SHIPPING INFORMATION
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| Name: | ||||
| Street address: | ||||
| Street address: | ||||
| City, State, Zip: | ||||
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CONTACT
INFORMATION - REQUIRED
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| E-mail address: | ||||
| Telephone: | ||||
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CREDIT
CARD INFORMATION
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| Credit Card Type (VISA-MC-DISCOVER): | ||||
| Name as it appears on Credit Card: | ||||
| Card Number: | ||||
| Expiration Date: | ||||
| Three Digit Security Code On Back: | ||||
| Signature of Card Holder: | ||||
