Please provide the following ordering information:

QTY	DESCRIPTION and size

Shipping

 Merchandise Total       Add

up to $19.00	$3.99
$19.01 to $39.00	$5.99
$39.01 to $59.00	$7.99
$59.01 to $79.00	$9.99
$79.01 to $99.00	$11.99
$99.01 to $149.00	$13.99
$149.01 to $199.00	$15.99
over $199.01	$17.99

     

	BILLING
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone number including  area code

	SHIPPING
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code