Charge my:
Mastercard
Visa
Name of Card Holder:
Card#:
-
-
-
Exp Date
Cardholder's Phone:
Cardholder's Address:
City, State Zip:
,
,
Shipping Address:
Same
Shipping Address:
Shipping City, State Zip:
,
,
Email:
Line
Prod#
Product Description
(Add $2 each for 2XL's; $3 each for 3XL's)
Qty
Color
Size
Unit Cost
Extended Cost
1
2
3
4
Shipping Chart
Up to $49.99..........
$6.50
$200.01 to $300....
$15.50
$50 to $100...........
$9.50
$300.01 to $400....
$19.50
$100.01 to $200.....
$12.50
$Over $400 add 5% of total
Sub Total:
Shipping:
Grand Total:
ALL PRICES INCLUDE TAX
(Make checks/money order payable to Image Concepts, Inc.)
