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PLEASE PRINT & COMPLETE THIS FORM, THEN MAIL OR FAX IT TO HALEY'S:
FAX: 978-249-9400 P.O. Box 248 Athol Massachusetts 01331 PHONE: 800-215-8805
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ITEM (PRINT CLEARLY)
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PRICE
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QUANTITY
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SUBTOTAL
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| Leading Chaos |
15.95 |
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Shipping & Handling $4.00 per item.
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TOTAL
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PAYMENT INFORMATION
| Name ________________________________ |
Phone ________________________________ |
| Email: _____________________________________ |
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| Please circle: VISAMasterCard |
Exp. Date ______________________________ |
| Card No ___________________________________ |
Signature ______________________________ |
BILLING ADDRESS
Address ______________________________
____________________________________ |
City _________________________ |
| State ____________________________________ |
Zip _________________________ |
MAILING ADDRESS (IF DIFFERENT)
Address ______________________________
____________________________________ |
City _________________________ |
| State ____________________________________ |
Zip _________________________ |
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