Nichols-N-Dimes.com Order Form (Order By Mail)

MAIL-ORDER FORM | Nichols-N-Dimes.com

(___) My Check Is Enclosed

(___) My Money Order Is Enclosed

(___) Bill Me Via PayPal

(___) Gift Certificate ID# __________

(___) YES! SEND OFFERS BY EMAIL.

SEND CHECK/MONEY ORDER TO:
Dept. WP-9999-1000
Attn: Mark A Nichols
105 N Main St
Crosby ND 58730

Make Payable To:
Mark A Nichols

Fax Order: 435-604-8161

NAME:

ADDRESS:
____________________________________ ________________________________

CITY: __________________________________ STATE: _____ ZIP: ____________

TELEPHONE:

EMAIL ADDRESS:

(__) CHECK HERE IF YOU PRINT ANY SPECIAL INSTRUCTIONS ON BACK

Name of Item	Choice (If Any)	Item #	Price Each	Qty	Price Total
1.
2.
3.
4.
5.
6.
7.
8. Store and/or Kit			$	1	$
9. BIG Gift Catalog			$9.00	1	$
10. Mail Order Catalog			$2.00	1	$

Store Version: __________ | Price: __________ | Choice: (_) Store (_) Store & Kit (_) Sub-Wholesaler Kit Only

THANK YOU FOR YOUR ORDER!

Merchandise Price Total	$
Sales Tax (if any)	$
Shipping & Handling	$6.00
Total Order Amount	$

OFFICE USE ONLY