Silver Birds

Handcrafted Jewelry

Mail Order To:

SHIP TO:

Silver Birds Jewelry

154 Eric Drive

Coventry, CT 06238

NAME: _________________________________

ADDRESS: ______________________________

________________________________________

STATE: ____________________ZIP: _________

DAYTIME PHONE: _______________________

ITEM # . . . . QTY . . . . DESCRIPTION . . . . . . .. . . . . PRICE . . . TOTAL . . . GIFT BOX

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EACH . . . . COST . . . . . ( Y / N )

_________ . _____ . ___________________________ . _______ . ___________ . _______

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SUBTOTAL ___________

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SALES TAX___________

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(6% CT Only) . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SHIPPING ___________

. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .TOTAL ___________

DO NOT SEND CREDIT CARD INFORMATION VIA INTERNET OR EMAIL!!

PAYMENT INFORMATION:

Personal Check/Money Order_____

Credit Card: . . . . . . . . . . . . . .

_____Visa _____ Master Card _____ Discover _____American Express

Card Number: __________________________________ Expiration Date: _____/_____

Signature: ______________________________________