Blackie's
Blend Order Form
Print
out, complete and Fax or Mail to:
Blackie's Blend
5523 SR 514
Glenmont, Ohio 44628
Fax: 330-378-2383
Date
___________________________
Name ___________________________________________________________________________
UPS Address ____________________________________________________________________
City or Town _______________________________ State ______________
Zip _______________
Phone No. ___________________________________ Ohio
County ________________________
Quantity |
Size |
Articles
Wanted |
Price |
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Amount
of Order |
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Postage
(see Ordering Information) |
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Ohio
Residents Add Your State Sales
Tax to Product & Postage |
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Total
Amount |
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Visa
or MasterCard usage at no charge.
Kind
of Card __________________________________
Card
No. _____________________________________
Expiration
Date _______________________________
Card
Holder's Signature: _____________________________________________________
(Make
sure to list ALL card numbers. A VISA will have 13 or 16 numbers.
A masterCard will always have 16 numbers.)
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