Name:____________________________________________________________

Address:_________________________________________________________

City:__________________________ State:__________ Zip:__________

Item #: Item Description Price
   
   
   
   
   
   
   
 Total 
 Shipping 
 Tax (MI 6%) 
 Total Enclosed 


Card Type16 Digit Card Number      Expiration Date
   
Verification Number (from back of card)

Signature:___________________________________________________________

Please make checks or money orders out to
Megan Bouchard

Print this form and mail it to the following address:
Megan Bouchard
P. O. Box 573
Hazel Park MI 48030-0573
If you wish, you can call us during business hours (8:30 AM - 5:00 PM ET) at (248)543-2696.