Order Form - Stevens Clogging Supplies, Inc.

You can print out the following ORDER FORM to place your order. (Please Print your information)
Mail to: Stevens Clogging Supplies, Inc. • P.O. Box 112, 49 Franklin Rd., Mercer PA 16137 • USA

SPEED YOUR ORDER
TOLL FREE 1-800-722-8040 USA 1-800-544-7824 USA & CANADA
TOLL FREE FAX: 1-800-531-9335 (24 HOURS)
OVERSEAS: 1-724-662-0808 OVERSEAS FAX: 1-724-662-2050 (24 HOURS)

BILL TO:_____________________________________________________        DATE:________________
(BE SURE TO GIVE YOUR PHYSICAL ADDRESS)
ADDRESS:__________________________________________________________________

CITY:________________ STATE:______ ZIP:__________ DAYTIME PHONE #: (____)____________

YOUR EMAIL ADDRESS: ______________________________________(For shipping and confirmation)

AMEX - VISA - MC NO._______________________________________ EXP. DATE:________ CID* NUMBER:_______
*CID is the 3-digit number on the back of your credit card.
IF SHIPPING ADDRESS IS DIFFERENT:                                                CREDIT CARDS
SHIP TO:____________________________________________   Do not forget expiration date.
ADDRESS:__________________________________________ MONEY ORDER (US Funds Only)
CITY:_______________ STATE:_____ ZIP:_____________  ORDERS paid by personal check are held 15 days.

Quantity	Cat. #	Color	Size*	Description	Price	Total

*Ordering shoes: Be sure to give both size and width (Example: 9W)

Totals

SHIPPING & HANDLING CHARGES: US: Orders under $50.00 add $6.00+UPS surcharge $50.01 - $100.00 add $7.00+UPS surcharge Over $100.00 - actual shipping costs+surcharge Call for cost quote or special instructions. UPS Ground Shipping Time USA INTERNATIONAL ORDERS	Please send the following information: (Tap) Attachment Flyer Last Flyer	Shipping & Handling Charges (See Information at left) □ Check here to allow us to automatically add fuel surcharge. Otherwise, we will need to call you..	_________
		PA Residents (ONLY) add 6% Sales Tax if Required	_________
		TOTAL AMOUNT	========

Thank You for Your Order!

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