Moose Creek Primitives
MooseCreekPrimitives.com
Order Date____________ PO#__________________ Customer #_____________________
Customer
Name:________________________________________________________________________
Billing Address:________________________________________________________________________
Credit/Debit Card
#_________________________________________ Expiration Date:_______________
Visa /Master Card/Discover/American Express
CVV#_______________ Buyers Signature:__________________________________________________
E-Mail Address:_______________________________ Buyers Notes:
_______________________________
______________________________________________________________________________________
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Ship to Additional Address____ (add $4.50 per
additional address with in the U.S)
Total Shipping Charges:______________
Total of entire Order:________________
Tax 5.5% (WI residents only)__________
Total Payment Enclosed:______________ Paid by
(circle or Highlight ONE) Personal Check (US ONLY),
US Money Order, Debit or Credit Card