|
First Name:
|
 |
Last Name:
|
|
|
Email Address:
|
|
Phone Number:
|
|
|
Address:
|
|
|
City:
|
|
State/Province:
|
|
|
Country:
|
|
ZIP/Postal Code:
|
|
|
|
|
|
Number of George
Bush Bush
seed packets ordered: __________ x $5.00 each =
|
$
|
|
Purchase
Amount
|
Shipping
Charge
|
|
Under $30.00
|
$2.50
|
|
$30 - $140.00
|
$3.50
|
|
$140.01-
$250
|
$4.50
|
|
$250.01
- $350.00
|
$5.50
|
|
$350.01
- $500.00
|
$6.50
|
|
$500.01
- $750
|
$7.50
|
|
$750.01
- $1000
|
$8.50
|
|
$1000.01
& above
|
$9.50
|
Total Shipping Charge=
|
$
|
|
MD residents
add 5% sales tax=
|
$
|
|
Total=
|
$
|
|
Method of Payment
-- Circle one:
Check | Money Order
Visa | Mastercard | American Express | Discover
|
If paying by check or money order,
please make it payable to
JPJ Group. |
|
If paying by
credit card, please fill out the information below:
|
|
Credit card number:
|
|
|
Expiration date:
|
Month/Year:
______/_______ |
|
Name as it appears
on credit card statement:
|
|
|
Billing Address
(if different from above):
|
Street: |
|
|
City: |
|
|
State: |
|
|
ZIP: |
|
Mail this form and
your payment (made payable to JPJ Group) or credit
card information to:
George Bush Bush, PO Box 90, Chester, MD
21619. Please allow 2 - 3 weeks for delivery.
|
