PRINT AND MAIL/FAX ORDER FORM TO

Hand Sculptured Glass
21 Raintree Drive
New Castle, DE 19720
Voice/Fax toll free 1- 877-771-4966

PLEASE PRINT ON FORM

        Name:_____________________________________________________

        Address ___________________________________________________

        City___________________________  State______  Zip Code_________

        Email Address_______________________________________

        Date_________ Telephone______________________


 Check one:    Check/MO____ Visa____ MC____ Discover______

Card Number__________________________________________ Expires_________ CVS (3digits on back) ______

                        Item Number      Quantity         Description                 Price

                        __________            ______    _________________  $_____________

                        __________            ______    _________________  $_____________

                        __________            ______    _________________  $_____________

                        __________            ______    _________________  $_____________

                        __________            ______    _________________  $_____________


Shipping flat rate method:
0 to $9.99 = $1.95
$10.00 to $49.99 = $6.76
$50.00 to $99.99 = $ $12.44
$100.00 to $199.99 = $14.71
$200.00 and up = $15.85		 Total $_____________

S&H $_____________

Grand Total $_____________


All information is confidential, and is not shared with parties other than those involved in this transaction.
Thank you for ordering from Hand Sculptured Glass at www.SculpturedGlass.com