Purple Pony Shirt Co. 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
 Mail to:

Purple Pony Shirt Company
4116 Main St.
Chincoteague, VA 23336

Checks, Visa, MC, AE Accepted
Flag Shirt Size and Price Details
11.95, Kids Small T-Shirt
11.95, Kids Medium T-Shirt
11.95, Kids Large T-Shirt

13.95, Adult Small T-Shirt
13.95, Adult Medium T-Shirt
13.95, Adult Large T-Shirt
13.95, Adult XLarge T-Shirt
13.95, Adult XXLarge T-Shirt

 17.95, Kids Small Sweat-Shirt
17.95, Kids Medium Sweat-Shirt
17.95, Kids Large Sweat-Shirt

21.95, Adult Small Sweat-Shirt
21.95, Adult Medium Sweat-Shirt
21.95, Adult Large Sweat-Shirt
21.95, Adult XLarge Sweat-Shirt
21.95, Adult XXLarge Sweat-Shirt
Item Size Quantity Price Subtotal
         
         
Virginia Sales Tax - Virginia Residents Only (4.5 percent of subtotal)  
Total (no charge for shipping within U.S.A.)  
Credit Card Information
____ Visa
____ Master Card
____ American Express
Name as it appears on the card ____________________________

Credit Card Number ____________________________________

Expiration Date (Month/Year) ________________

Signature _________________________________

Billing & Mailing Address

Name

Apt. Number

Street Address

City

State & Zip

Telephone

Email