PRINTABLE ORDER FORM

Print and mail to:
DOWN MEMORY LANE
715 CARROLL ST.
BOONE, IA 50036
or fax to: 515-432-3222

Item
Number		 Description Quantity Price Each Total
         
         
         
         
         
         
         
         
         
Shipping to USA or Canada:
 0 to $10.00 - $5.15
$10.01 to $20.00 - $6.15
$20.01 to $30.00 - $7.20
$30.01 to $45.00 - $8.25
$45.01 to $60.00 - $9.25
$60.01 to $75.00 - $10.30
$75.01 to $90.00 - $11.35
$90.01 to $100.00 - $12.35
$100.01 UP - $13.35
1 or 2 patterns - $2.50
International Orders Contact Us For Quote

Subtotal $___________
 Iowa Residents - Add Your City's Sales Tax $___________
Shipping $___________
TOTAL $___________

Bill To: Ship To: (If different)

Name:____________________________
Address:__________________________
City:_____________________ State:_____
Zip:________
Daytime Phone:(         )                                    
(Used only if we have a question regarding your order)

 Name:____________________________
Address:__________________________
City:_____________________ State:_____
Zip:________
E-mail:___________________________

Check or Money Order in U.S. funds made out to DOWN MEMORY LANE, enclosed

VISA    MASTERCARD    DISCOVER

CREDIT CARD NUMBER:________-________-________-________    EXP.DATE:______/______

SIGNATURE:__________________________________    DATE:_________________