Order Form (Please Print) |
Pine Island Primitives 16369 County 11 Blvd. Pine Island, MN 55963 507-356-2908 rugs@bevcomm.net |
Mailing Address: | |
Name: | |
Address: | |
City: State: Zip: | |
Phone: Email: |
Payment Method: (Check One) US DOLLARS ONLY |
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___ Check ___ Money Order ___ Credit Card |
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Card Number: | _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ | Exp. Date: _ _ / _ _ |
Name on Card: | Last 3 Digits on back - _ _ _ |
If paying by check or MO please make to: Pine Island Primitives |
Quantity | Description | Price | Total | |
US Shipping & Handling: |
Subtotal |
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Tax 6.875% (MN only) |
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Shipping | ||||
Balance Due |
Thank you for your order. We appreciate your business. |