Sallamah's Suq Order Form
Order Form for Book, Patterns, Video Tapes, etc. Name:_________________________________________________________________________ Address:________________________________________________________ Apt#_________ City:______________________________________________ State:______ Zip:_________ Phone Number(s): (_____)_____________________________________________________ Permanent E-Mail
Address:___________________________________________________ |
Quantity: |
Item Number: |
Description: |
Unit Price: |
Total Price: |
| Sub-Total: | $ ______________ |
| Shipping: | $ ______________ |
| 6.25% Tax: | $ ______________ |
| TOTAL: | $ ______________ |
Please Make Checks Payable to:
Ethnic Dance Expressions
Circle
Credit Card:
VISA
or Master Card
Credit Card Number:
_______________________
Expiration
Date:______________
Last 3 digits over Signature:________
Your Signature as it appears on your Credit:
Signature: ________________________________________________
Print
and fill it out Order Form then
either Fax or E-mail it to:
Fax: 352-379-1056
E-mail: sallamah@bellsouth.net
B
2004 Sallamah Chimera