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Bill
to
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| First
Name: ______________________ Initial: ________ Last Name: _______________________ |
| Address:
________________________________________________________________________ |
| City:
____________________________ State: _____________________ Zip:
________________ |
| Daytime
Phone: _________________________________________________________________ |
| Email:
_________________________________________________________________________ |
| |
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Ship
to if same as above check here (
)
|
| First
Name: ____________________ Initial: ________ Last Name: ________________________ |
| Address:
_______________________________________________________________________ |
| City:
____________________________ State: _____________________ Zip:
________________ |
| Daytime
Phone: _________________________________________________________________ |
| Email:
_________________________________________________________________________ |
| |
|
Order
Information
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Style
#
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Color
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Quantity
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XS
6
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S
8
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M
10
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L
12
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XL
14
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1X
16
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2X
18
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3X
20
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4X
22
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5X
24
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6X
26 |
Unit
Price
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Amount
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| Total
Quanity = |
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Total
Amount= |
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Payment
Option (Check one)
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| CREDIT
CARD ( ) |
| Credit
Card Number: ______________ /_______________ /______________
/_______________ |
| Expiration
Date: _______ /______ /______ |
| Credit
Card Type (Please circle one): Visa / MasterCard / AMEX / Discover |
| Cardholder's
Name (as it appears on the card):
___________________________________________ |
| Cardholder's
Signiture (Card Holder Aggrees to pay Discount Dresses the Total
Amount above:
Signiture: ________________________________________________
Date: _____/____/____
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| MONEY
ORDER / CHECK ( ) |
| Please
make your Money Order/check payable to DISCOUNT DRESSES and
mail it to |
|
Discount Dresses,
3105 N. Ashland, Suite 222,
Chicago, IL 60657.
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| Special
Shipping Instructions (below): |
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By
signing customer agrees to the following terms and conditions
and order policy:
- Non-authorized refusal/returns
will result in freight claims.
- Please allow 48
hours for the order to be processed and shipped.
Customer's Signiture
(Required): Signiture:
Signiture:
________________________________________________
Date: _____/____/____
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