Mail:

Timeless Treasures 3761 Brownlea Rd Silsbee, TX 77656

Fax:

(409)386-0442

Ship To

Name:		Phone  (       )         -
Street:
City:	State:	Zip:	Country:
Email:	Fax#:

Products

Qty	Item Number, Size and Color	Price Each	Subtotal
		Subtotal
Shipping - (See Chart Below) U.S. Only
TOTAL

Shipping Chart

Purchase Amount	Shipping Cost	Purchase Amount	Shipping Cost
Up To $50.00	$5.95	$150.01 - $200.00	$8.95
$50.01 - $100.00	$6.95	$200.01 - $250.00	$12
$100.01 - $150.00	$7.95

Billing Information

Circle One:

VISA

MC

AMEX

DISCOVER

Credit Card Number:               -               -               -                  Expires M/Y:               /                             CVV2 Code:

Name on Card:                                                                                 Phone  (            )                -

Credit Card Billing Address (where statements are mailed)
Street:
City:	State:	Zip:	Country:

Signature:

Date: