Order for Milagros - print this page

Date_________________

Name___________________________________________

Address: Street or PO Box___________________________

_________________________________________________

City/State/Zip______________________________________

25 milagros_________________ $14.99 ________

50 milagros_________________ $28.98 ________

75 milagros_________________ $42.97 ________

100 milagros_________________ $56.96 ________

150 milagros_________________ $84.94 ________

200 milagros_________________ $112.92 ________

Shipping charges included (with delivery confirmation)

insurance__________ $3.00 ________
 
Signature ______________________

Send to: Bryant Holman
POBox 470
Presidio, TX 79845

I am not responsible for items lost or stolen in the mail. Your signature
attests you aggreement with these terms.