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Anne Koplik Designs
173 Main Street
Brewster, New York 10509
(800) 542-3134
| Style # | Color | Quantity | Unit Price | Amount |
PLEASE NOTE:
A 12% Surcharge will added to all orders
OK to substitute color? ___Yes ____No
OK to substitute similar style and price? ____Yes ____No
If ordering earrings, would you like the earrings on cards? ____Yes ____No
If ordering pins, would you like the pins on cards? ____Yes ____No
Shipping Information
How would you like us to ship your order?
UPS Ground
UPS Second Day Air
UPS Overnight
UPS Ground to Canada
UPS International – Please e-mail for details
ORDERS PROCESSED ON A "FIRST COME FIRST SERVED" BASIS
ORDERS TO BE SHIPPED BETWEEN 1 AND 5 BUSINESS DAYS
Ship Order To:
Name: ________________________________________
Company: ________________________________________
Street Address: ______________________________________
City: ________________________________________
State: ________________________________________
Zip Code: ________________________________________
Business Address OR Home Address
Billing Information
Select the applicable terms for your order.
C.O.D.
Net 30
‘As Before’
Credit Card
Bill Order To:
Check here, if Billing Address is the same as Shipping Address
Company: ________________________________________
Street Address: ________________________________________
City: ________________________________________
State: ________________________________________
Zip Code: ________________________________________
Country: ________________________________________
E-mail Address: ________________________________________
Business Phone: ________________________________________
Alternate Phone: ________________________________________
Tax ID # for
NYS Residents: ________________________________________
Credit Card Information
VISA
Mastercard
American Express
Expiration Date: ________________________________________
3 Digit Code (back of Card): ________________________________________
Name on Card: ________________________________________
Billing Address on Card: ________________________________________
City and State: ________________________________________
________________________________________