Mail To: Prairie Rose Jewelry PO Box 922 Pagosa Springs, CO 81147
Payment By	Check Money Order Credit Card
If Paying By Credit Card
Name On Card
Card Type	American Express Master Card Visa Discover
Card Number
Expiration Date (mm/yy)
Sold To
Name
Address
Address Cont.
City		State
Zip		Country
Telephone		Email
Ship To
Name
Address
Address Cont.
City		State
Zip		Country
Item Code Item Name Price Total Order 1 Order 2 Order 3 Order 4 Order 5 Order 6 Order 7 Order 8
	Sub-Total
	Shipping
	Total
Shipping	Standard ( $7.00 Priority Mail w/ Insurance ) Express Mail 2 Day ( $18.80 )
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