Simpsons Jewelry & Uniforms Order Form

SIMPSON JEWELRY & UNIFORMS, INC.
TELEPHONE/FAX ORDER FORM
Fax: (765) 628-2598    Phone: (765) 628-7674
Shipping Information

Name: __________________________________________________________________

Address: __________________________________________________________________

City/State/Zip: __________________________________________________________________

Telephone #:
  Home: _____________________________   Bus.: _____________________________

Name of Commandery: __________________________________________________

Council/Chapter: __________________________________________________

Billing Information (if different from above)

Name: __________________________________________________________________

Address: __________________________________________________________________

City/State/Zip: __________________________________________________________________

Telephone #:
  Home: _____________________________   Bus.: _____________________________

Payment Information

Master Card or Visa #: ______________________________ Exp. Date: _____ / _____ / _____

C.O.D.: ______________________________

Check or Money Order in advance of shipment: ______________________________

Item Information

QTY ITEM #    ITEM DESCRIPTION ITEM PRICE TOTAL

______   ____________________   ________________________________________   _____________   _____________

______   ____________________   ________________________________________   _____________   _____________

______   ____________________   ________________________________________   _____________   _____________

______   ____________________   ________________________________________   _____________   _____________

______   ____________________   ________________________________________   _____________   _____________

Sales Tax: _____________

Freight: _____________

Balance Due: _____________

Name of Commandery:	__________________________________________________
Council/Chapter:	__________________________________________________

QTY	ITEM #	ITEM DESCRIPTION	ITEM PRICE	TOTAL
______	____________________	________________________________________	_____________	_____________
______	____________________	________________________________________	_____________	_____________
______	____________________	________________________________________	_____________	_____________
______	____________________	________________________________________	_____________	_____________
______	____________________	________________________________________	_____________	_____________
Sales Tax:				_____________
Freight:				_____________
Balance Due:				_____________