HOME  Bonnie Prior & Company 

PO Box: 78865  Charlotte, NC 28271

Date:_______________________

Name:_____________________________________________________________________

Street Address:______________________________________________________________

City:____________________________  State:________  Zip Code:____________________

Phone Number: _________________________    Fax Number: _______________________

Email Address: _________________________________________________

Item #            QTY             Description:                                               Unit Price:          Total:

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                                                                                    Sub Total: ___________ 

                                                                                   + Shipping:  ___________ 

                                                                                             Total: ___________

Payment Option: Personal Check        Money Order        Credit Card (Visa/Mastercard/Amex)        

For Credit Card Purchase Only:                  Card Type:    Visa   /     Mastercard    /   American Express

Credit Card Number: _______________________________________________________  Expiration Date: __________

Name On Credit Card: ______________________________________________________________________________

Ship Address: ___________________________________________________________________________________

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If using Gift Service: Please write message to be sent to recipient:

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Order confirmation: (please circle one)    fax     or    email        (If more space is needed, please use a separate sheet of paper)

Name:   __________________________ Signature: ___________________________

Fax form To: (704)821-2837 or mail to above address