Mail completed form with payment to:
PROUD SHOPPER
POB 1862
FALKVILLE AL 35622
Proud Shopper Mail Order Form
Best printed "to fit" in LANDSCAPE orientation
proudrebel.com proudcowboy.com proudflag.com proudpirate.com proudtexans.com

Date:____/____/ 20___

Page: ___ of ___

Buyer Name: _______________________
Street: ____________________________
City: _______________ State:___ Zip:_______		 Ship to (if different): ______________________
Street: ______________________________
City:_______________ State:___ Zip:_______
Phone: ____ - ____ - ______ Ext. _____
Fax: _____ - _____ - _______
Email: _______________@__________		 Buyer address MUST match card billing address.
Credit Card no.: _____-_____-_____-_____
Name on card:_______________________
Expires:___/____ 3-digit code on back:____
ITEM DESCRIPTION - no item number needed, but be SURE to list sizes QTY $ EACH $ TOTAL
1 . . . .
2 . . . .
3 . . . .
4 . . . .
5 . . . .
6 . . . .
7 . . . .
8 . . . .
9 . . . .
10 . . . .
. SUBTOTAL $
ONLY deliveries to Alabama include 7% sales tax SALES TAX $
Include $5 for Priority shipping, or
$21 for Flat-Rate Envelope Express, $24 for non-envelope Express, or $34 for heavy package (4lb+) Express		 SHIPPING $
Checks are held for 10 days to verify clearence.
Allow up to 3 weeks for non-Express delivery. No Express orders by check!		 TOTAL $