Name: __________________________________________________

Address: __________________________________________________

City: __________________________________________________

State: __________________________________________________

Zip: __________________________________________________

Phone: __________________________________________________

Daytime Phone: __________________________________________________

Payment type...
Money Order
Cashiers Check
Personal Check # __________
Cash
Visa/Mastercard (Circle One)
Card # __________________________________________________
Card Exp Date __________

Signature: __________________________________________________

Date: __________________________________________________

Quanity	Description	Unit Price	Total
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
_____	__________________________________________________	__________	__________
Sub Total			__________
6% (Indiana's Sales Tax) *			__________
Total			__________

* Residents outside of Indiana do not pay sales tax, unless customers pick items up from store.