Date: ____________________________

Sold To: ____________________________

____________________________

Phone: ____________________________

Visa/Master Card # ___________________

Exp. Date: ___________________

Quantity	Description	Price	Amount









	Sub Total:
	UPS: $6.00 for first stein, $2.00 each additional
	Illinios State Sales Tax: 6 ½ % for Ill. Residents
Total Amount Due:

For Office Use Only

Date Shipped __________________ Zone ______________________ Lbs.______________