Jerry's Harness Shop Order Form

Printable Order Form

Mail this form with your check, money order or credit card information to:

Jerry's Harness Shop, P O. Box 94 ,Greenwood, MO 64034

(816) 554-1255

All products are made to order and delivery time is 4 to 6 weeks

after order has been placed.

Print this form from your browser. Click file then print.

QTY.	ITEM #	SIZE	LEATHER COLOR	PAD COLOR	BUCKLES "B or S"	DESCRIPTION	ITEM PRICE	TOTAL

Visa

MasterCard

	Expiration Date


	Please Charge my Credit Card Account Number listed below:

Acct. #______________________________

Card Holder Signature:
_______________________________________________________

Daytime Telephone Number: _______________________________________________________
Email Address: _______________________________________________________

All products are made to order and delivery time is 4 to 6 weeks after order has been placed.

Sub Total
6.976% Sales Tax - MO. residents only
Shipping Charges (See chart)



Total Amount Due

Purchase Amount	Shipping Charge
$ 0 to $75.00	$9.95
$75.01 - $100.00	$11.95
$100.01 - $125.00	$13.95
$125.01 - $200.00	$15.95
$200.01 - $250.00	$16.95
Over $250.00	$17.95

Bill TO:

Name: ___________________________

Address: _________________________

City:_____________________________

State: _________ Zip Code: _________