|
ORDER FORM (Please print and mail) |
| SIZE |
PRODUCT NUMBER |
PRICE |
NUMBER ORDERED |
TOTAL |
| Child's Small (6-8) |
G-200201 |
$ 9.95 |
|
|
| Child's Medium (10-12 |
G-200202 |
$ 9.95 |
|
|
| Adult Small (34-36) |
G-200203 |
$ 10.95 |
|
|
| Adult Medium (38-40) |
G-200204 |
$ 10.95 |
|
|
| Adult Large (42-44) |
G-200205 |
$ 10.95 |
|
|
| Adult X-Large (46-48) |
G-200206 |
$ 10.95 |
|
|
| Adult XX-Large (50-52) |
G-200207 |
$ 11.95 |
|
|
| Fight tobacco-related
disease pin |
P-300001 |
$ 5.00 |
|
|
|
Please print and complete this
order form, and
mail with
check or money order
payable to:
SmokingHurts.com
8810 Brae Crest Dr.
San Antonio, TX 78249-3835
Questions: (210) 522-1167
Ask for Jacque
or email us at
jacque@smokinghurts.com.
Thank you. |
SUB-TOTAL |
|
Number of free bumper
stickers
1 (one) per t-shirt or tobacco pin ordered |
|
$0.00 |
| Shipping: |
$2.50 |
| TOTAL |
|
|
| BILL
TO
(Please type or print) |
|
Name:_____________________________ Phone #s: (_____)___________
(______)__________
Address:______________________________________________________________________
City:______________________________________________ State:____
Zip:_______________ |
| Comments: |
| |
|
| SHIP TO
(Please type or print) IF DIFFERENT FROM THE ADDRESS ABOVE |
|
Name:_____________________________ Phone #s: (_____)___________
(______)__________
Address:______________________________________________________________________
City:______________________________________________ State:____
Zip:_______________ |
| Comments: |
| |
|
|
Thank you! |