H & H Pharmacy Mail Order Form - from Chincoteague Shopping
Instructions:
  1. Print out this form
  2. Fill in the information
  3. Determine the total cost of the items
  4. Virginia residents add  4.5 % sales tax
  5. Add shipping and total
 Mail to:

H & H Pharmacy
6300 Maddox Blvd 
Chincoteague, VA 23336

Checks, Visa, MC, or Discover Accepted
Color & Price Details
Solid colored blue: $35.00
Solid colored green: $35.00
Multi-colored: $49.00
Item Color (see above) Quantity Price Subtotal
         
         
Virginia Sales Tax - Virginia Residents Only (4.5 percent of subtotal)  
Shipping: $8.00 per Afghan  
Total  
Credit Card Information
____ Visa
____ Master Card
____ Discover
Name as it appears on the card ____________________________

Credit Card Number ____________________________________

Expiration Date (Month/Year) ________________

Signature _________________________________

Billing & Mailing Address
(No Post Office boxes)

Name

Apt. Number

Street Address

City

State & Zip

Telephone

Email