2896 Havenwood Dr White Lake, MI 48383-3902
** PLEASE PRINT CLEARLY! **
|Item Name or Number||Color/Details||Price Each||Quantity||Total|
|Date of Order:||Total Due $|
|Please make checks or money orders payable to: Heirloom Pottery|
|Charge cards accepted: Visa and MasterCard|
|Credit Card #||Exp. Date:|
- [ ] Check here if you wish item to be shipped to address other than indicated above ... please write person's name and their shipping address on back of this form.
- We must include sales tax for Michigan residents
- THANK YOU FOR YOUR ORDER!