Purple Harmony Plates (USA)
44 Ruggles St, Westboro MA 01581
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Phone/Fax |
Order Form |
Please Print Clearly
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(508) 898-1970
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Credit Card Purchase |
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Please Ship My Order To |
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Circle to Select: |
Visa Mastercard
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Name: |
Name: |
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Address: |
Amount (USD): |
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City: |
Credit Card No: |
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Expiration Date: |
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State: |
I hereby certify that I am (Name as presented on Card)
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Zip Code: |
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Country: |
and that I authorize an amount of (in words):
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Telephone: |
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Please make checks payable to Purple Harmony Plates or complete the credit card details on the right. |
to be deducted from the above circled credit card. I undertake to reimburse Purple Harmony Plates the sum shown above in the event of the transaction being rejected. |
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Thank you for your order and Expect A Miracle!
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Signed: |
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