
| Qty. | Item | Size | Fragrance | Price | Sub Total |
|---|---|---|---|---|---|
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| _________ | ______________ | _________ | _________ | _________ | _________ |
| Sub Total: $ |
| Add Shipping (see chart below): |
| Florida Residents Please add 6% Sales Tax: |
| Total Enclosed: $ |
| Payment Options: Circle One |
| Credit Card Number: |
| Expiration Date: |
| Name on the Card: |
| Company Name: |
| Name: |
| Address: |
| City/Providence: |
| State & Zip Code: |
| Country: |
| Phone with Area Code: |
| Fax with Area Code: |
| Email: |
additional item, shipped to the same location. Starfish 1 - 3 items $3.75 or add $1.10 each if shipped with a Pie or Rack. |

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