Queen of the Holy Rosary Mediatrix of Peace Shrine
ORDER FORM
PLEASE PRINT LEGIBLY: DATE: ________________________
NAME:
___________________________________
ADDRESS: _______________________________
CITY: ___________________ STATE:___________ ZIP: ____________
COUNTRY: ________________________
PHONE: ___________________________ E-MAIL: ____________________
ITEM NUMBER |
DESCRIPTION |
COLOR/ SIZE |
QTY |
PRICE PER EACH ITEM |
TOTAL PRICE |
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WI residents only – add 5.5% sales tax |
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Total Amount Due |
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