BICHON BOUTIQUE ORDER FORM

If paying by VISA or MasterCard, print this form, fill out, and fax to Jill at 301-762-6422. If no fax available, charge orders may be phoned in to 301-762-6022 between noon - 9 PM Eastern time. If paying by check or money order, print and complete this form and mail with payment. Make checks payable to MARYLAND BICHON FRISE RESCUE, INC. and mail to MBFR - Jill Siegel / 13400 Valley Dr. / Rockville, MD 20850. Orders paid by personal check will be processed after check clears. (n2)

Name (if charge, Cardholder Name)
Billing Address
City, State, ZIP
Daytime Phone
Email Address
Form of Payment: VISA ____ MasterCard ____ Check/Money Order ____
Credit Card #
Expiration Date (mm/yyyy)
CVV2/CVC2/CID
3-digit # on back of card

IF SHIPPING TO A DIFFERENT ADDRESS, PLEASE PROVIDE IT ON A SEPARATE SHEET.

ORDER - If need more space, write additional items below chart or under Special Instructions

Quant.
Item Name
Size Color Item # Price
Shipping
 Total Cost
          $ $  $
          $  $  $
          $  $  $
          $  $  $

Merchandise Total:   _________

6% Sales Tax (Maryland orders only; no tax on shipping): _________

GIFT WRAP (specify below if for Christmas, Chanukah, or other occasion) @ $2.50 per item: _________

TOTAL PAYMENT :   __________

Special Instructions


Thank you very much for your order!
* 100% of the profits go to Bichon Rescue to help bichons in crisis *