Henry Derby Flowers, Order Form - Salem, Massachusetts

49 Summer Street, Salem, MA 01970

To place orders:
Call 978-745-1080
7 days a week 9 to 5
Credit Card Orders Only
or
Fax Order 24 hours a day

Order Form
Ordered by:	Ship to: (if different)
Name _________________________________	Name ________________________________
Address________________________________	Address_______________________________
City, State, Zip__________________________	City, State, Zip__________________________
Telephone _____________________________	Telephone _____________________________

Item No.	Product Description	Quantity	Unit Price	Total Price
_______	_________________________________	___	_______	_______
_______	_________________________________	___	_______	_______
_______	_________________________________	___	_______	_______
_______	_________________________________	___	_______	_______
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Payment Method Please do not mail cash. All checks must be in U.S. dollars. [ ] Check / Money Order [ ] MasterCard [ ] Visa [ ] Discover Account Number___________________________________ Signature_________________________________________ Expiration Date _____________		Subtotal ________ MA Delivery 5% sales tax ________ Shipping charge ________ TOTAL ________

Shipping & Handling

Merchandise
Total Up to
$20.00 $20.01 -
$40.00 $40.01 -
$60.00 $60.01 -
$100.00 $100.01 -
$600.00
Shipping &
Handling $ 4.95 $ 7.95 $ 8.95 $ 9.95 $11.95
For orders outside the U.S., call for shipping information.
All orders shipped UPS Ground, unless otherwise specified