BASILE MERCHANDISE ORDER FORM

Print this form and fill out.

Then send or fax.

Basile's On-Stage Services
PO BOX 15026
Wilmington, North Carolina 28408

FAX - 1-910-799-5227

Product Description	Color	Size	Quantity	Total
SUBTOTAL ->
North Carolina Residances please add 5% Sales Tax ->
Add Shipping Charge for the first $40 ->				$ 5.00
Please add $5 shipping for each addtional $40 of merchandise ->
GRAND TOTAL ->

DO NOT SEND CASH
Please enclose check or fill out the credit card information below

Make Checks Payable to: BZK On-Stage Services

Circle One: VISA MASTER CARD

Name of Card Holder: ___________________________________

Account Number : _______ -________ -________ -_________

Expiration Date:________________________
Phone Number (incl area code):  ____________________________

 

Signature: ___________________________________________

 

SHIP TO WHAT ADDRESS:

Name __________________________________________________________

 

Address ________________________________________________________

 

City ______________________________ State ______ Zip ________________

 

Thank you for your Order!