Order Form

Name: _______________________________Phone: (____)_____________________

Address: _____________________________________________________________

City: ________________ State: _______ Zip: _________ e-mail: ________________

Method of Payment: __ Check _ Money Order

Item Name / Description	Qty	Price	Total
			$
			$
			$
			$
			$
			$
			$
			$
			$
Order Total:			$
Michigan Residents Add 6% Sales Tax:			$
Shipping and Handling Charge:			$
$ 0.00 to $20.00 add $4.95 US $9.95 International
$20.01 to $35.00 add $5.95 US $11.95 International
$35.01 to $50.00 add $6.95 US $13.95 International
$50.01 to $74.99 add $7.95 US $15.95 International
$75.00 up Free US shipping $17.95 International
Total:			$

Print this order form, fill-in the information and mail it w/check or money order to:

Circle D Western

5371 Coit Ave NE

Grand Rapids, MI 49525