Print this form, fill it out, and mail or phone it to us.
ORDER FORM

KIRSTEN
 910 Lenora Street, Suite 156
Seattle, WA  98121

Phone: 206-286-0851
email:stacy@kirstenpipe.com

Order Date

___  / ___  / ___
 
If you are shipping this order to someone else, please print their name to the right, and your (purchaser) name in the empty space below.  

    

SHIP TO___________________________________________

ADDRESS__________________________________________

CITY___________________STATE__________ZIP________
 
                                         

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Check, Money Order, or Cash for $_____________________

American Express          ______________________________
Master Card                                       Card Number
VISA                                ______________________________
                                                              Exp. Date
 
QUANTITY NAME  OF  ARTICLE FINISH,  STYLE,  SIZE PRICE
                                                                                                                                                       
                                                                                                                                                        
                                                                                                                                                        
                                                                                                                                                        
                                                                                                                                                        
                                                                                                                                                        
*SHIPPING AND HANDLING CHARGES

$3.00 for o-rings
$6.50 for orders to WA State
$12.50 to other states
contact us for outside USA

**Washington State residents please add 9.5% sales tax         
SUBTOTAL                        
SHIPPING  
TAX**  
TOTAL  

*Within the USA only. Please contact us by e-mail for shipping charges outside the USA

If you would like our CATALOG sent to any of your friends, please write their names and addresses below. 
We will forward a copy at once.  IT'S FREE.

  Name_____________________________________

Address___________________________________

City_________________State_______Zip_______		   Name_____________________________________

Address___________________________________

City_________________State_______Zip_______