Payment Received By: By:

Sold To: Sold By :

Address:

e-mail: e-mail:

Phone: Phone:

ITEM # DESCRIPTION SCENT COLOR TOTAL

$0.00 to $ 14.99 $ 6.95 ______________

$15.00 to $37.99 $ 8.95 ______________

$38.00 to $74.99 $12.95 ______________

$75.00 to $99.99 $14.95 _____________

$100.00 to $149.99 $19.95

SHIPPING:

______________________________

______________________________

SUBTOTAL:

UNIT PRICE

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____________________2105 E State Road 14

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Rochester, Indiana 46975

Collins Country Gifts

[e-mail] lola@rtcol.com

P O Box 1014 Order Date:

Delivery Date: ____________________

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$150.00 to $199.99 $27.95

$200.00 to $299.99 $34.95

7% SALES TAX:

TOTAL PAID:

Payment Received By: By:_____________________