Pumpkin Patch Eyeworks Printable Order Form
Print this form, visit the store for the patch name(s) you want to order, fill it out and mail along with a check
or money order to:
                
       Lisa Rose
       1718 Rustic Oak Ln.                          *After you have printed this page, simply
       Seabrook, TX 77586                           close it out to return to our web site.
                                                              
Name:_________________________________________ Date :  ___________________

Address:___________________________________________ Payment:

City, State, Zip:______________________________________

Phone:_____________________________________________

E-Mail:_____________________________________________
                                                     Sub Total:____________

                                   *Shipping & Handling:____________                       
           Tax (8.25% for Texas Resident Only):____________
                                                       
                                                         TOTAL:____________
*SHIPPING AND HANDLING FEES
                          Inside the United States       
         $ 0 - $30   = $3.50                 $111 - $140 = $11.50
         $31- $60   = $5.50                 $141 - $170 = $13.50
         $61- $90   = $7.50                 $171 - $200 = $15.50
         $91- $110 = $9.50                 $201 - $230 = $17.50

         Outside the Unites States, add an additional
          $2.00 to the above fee
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|______________________|__________|_____|_________|_________|
|______________________|__________|_____|_________|_________|
|______________________|__________|_____|_________|_________|
|______________________|__________|_____|_________|_________|
*No information is sent over
the Internet.  Please make
checks/money orders payable
to Lisa Rose.
  
        Patch Name in Store or              Right or 
    Describe Your Special Order         Left Eye            Qty         Unit Price           Total
_______________________________________________________________________
                                                                                      
    
Check
Money Order