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!