The Ladies' Parlor                             P.O. Box 274
                                                                                                        Kahoka, MO. 63445
                                                                                                        660-727-3592
                                                                                                        660-727-2086  fax

http://www.theladiesparlor.com

Date                                                           e-mail: parlor@nemr.net

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 Please print this form, fill in items and mail or fax to the above address.

Name:

Address:

City/State/Zip:

Phone:

E-mail:

Quantity	Description	Unit Price	Total
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Subtotal

MO. Tax 7.225 only for MO. Residents

Shipping

Total Due

Shipping & Handling
$30.00 and under  --  $4.05        ____ ____ ________
$30.00 to $50.00    --  $4.50                      Check one of the above.
$50.00 to $100.00  --  $6.00  Name of Bank_______________________________
Over $100.00           --  $7.00    Expiration Date______________________________
                                                        Cardholder Name____________________________
                    Card Numbers  __  __  __  __    __  __  __  __    __  __  __  __    __  __  __  __
Thank you for your order.
Make check or money order payable to The Ladies' Parlor.      HOME