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Buckles Etc.

732 Tracy Circle Unadilla, Ne. 68454-4261     Phone 402-828-2222    Fax 402-828-2223

BILL TO:

NAME_____________________________________

ADDR._____________________________________

CITY______________________________________

ST._________ZIP____________________________

PHONE____________________________________

FAX_______________________________________

E MAIL____________________________________

SHIP TO:   (If different from bill to)

NAME_____________________________________

ADDR._____________________________________

CITY______________________________________

ST._________ZIP____________________________

PHONE____________________________________

FAX_______________________________________

E MAIL____________________________________
QUANTITY

ITEM NUMBER &  DESCRIPTION

PRICE EA.

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUB-TOTAL

 

Checks or M.O. Payable to Buckles Etc.    (sorry no C.O.D.)

NE. SALES TAX 5.5%

 
        ---         ---         ---        
Shipping  (USA)     

$12.00

 ( $1.00 per $100.00 Ins. )  

___ MASTER CARD OR ___VISA  Expiration Date ____/____

We need the last 3 digits from the back of the card __ __ __CVV code

Authorized Signature__________________________________

TOTAL

 

(Please be sure we have the correct billing address for your credit card!)

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