Product Order Form

shirleynealcarterkennedy.com
631 Greystone Avenue
Jacksonville, North Carolina  28540

Phone: (910) 347-1797
Fax: (910) 347-1797
www.shirleynealcarterkennedy.com

Date     (mm/dd/yy)

Ordered By:: Deliver To: (if different from order address)
Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
   
ITEM DESCRIPTION   QTY UNIT PRICE AMOUNT
 
 
 
 
 
     
PAYMENT:
Personal Check
Money Order
Is this a gift for someone else?
 
Yes
No
If Yes, please provide name for inscription,


(enter name exactly as you want inscription to read)
     

Print two copies of the completed order form and keep one copy for your records. Mail the other copy and a check or money order to:

shirleynealcarterkennedy.com
 631 Greystone Avenue
Jacksonville, North Carolina  28540

Phone: (910) 347-1797
Fax: (910) 347-1797
www.shirleynealcarterkennedy.com

We thank you for your order!                                                                                                                                                                                       


Copyright © 2003 shirleynealcarterkennedy.com. All rights reserved.
Revised: 02/06/10