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

KIRSTEN
1900 W Nickerson St. #112
Seattle, WA  98119

Phone: 206-286-0851
Fax:     206-286-8891
email:stacy@kirstenpipe.com

Order Date

___  / ___  / ___
 

 

Every tobacco product shipped requires an adult signature at the point of delivery.  Without an adult signature, no delivery will be made.

 

    

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

On orders less than $10.00, add $3.00 s&h
On orders $10.00 or more, add $6.50 s&h

**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 have not yet provided the below “Proof of Age Form” then we must receive this from you before we can process your order.

Please print and sign.  We must also receive a clear, readable copy of your Driver License in order to ship to you.

You can send a copy of your driver license via email or postal service, but a FAX copy is not acceptable.

 

I certify that I am at least legal minimum age (currently 18 years old) to purchase tobacco.

 

I certify that I live at

            Street Address  ____________________________________________

            City  _________________________  State  ________  Zip  ________

 

I am providing a photocopy of my valid, verifiable ID, specifically my _______________________ (Driver License, Passport, etc)

 

I understand that signing another person’s name to this certification is illegal.

 

I understand the purchase of tobacco by individuals under the legal minimum age is illegal.

 

Printed Name _____________________________________________

 

Signature  ________________________________________________