Name:
Address:
Box #:
City:
State: Zip:
Date:
Email:


Quantity Item Design Price Total
Baby Bootie pink rose/blue rose (include info) $17.95
Baptismal Cross pink rose/blue rose (include info) $19.95
Bisque Egg tame rose/wild rose/pansy/lilac $44.95
Ball Ornament wild rose/winter scene $14.95
Ornament Stand For display $3.00
Lefse Sugar Shaker wild rose/pansy/lilac $22.50
Lutefisk Butter Pitcher wild rose/pansy/lilac $22.50
Matching Lefse Tray wild rose/pansy/lilac $39.95
Lefse 3 pc. Set (save $5 on set) wild rose/pansy/lilac $79.95
Wild Rose Cards 8 pack $6.95
M.Lark/Wild Rose Ornament North Dakota and/or 2012 $12.50

Quantity Art Supplies and/or Studies Price Total

PAYMENT METHOD
Date:
Check or Money Order $:
MasterCardCheckOther
VisaMoney Order

Complete Credit Card No.:

Expiration Date:

3 digit security No. on the back of card:


__________________________________
Customer Signature
Shipping & Handling:
Up to $24.99   30%
$25.00 - $49.99   25%
$50.00 & up   20%
Subtotal
Sales Tax 7%
(ND residents only)
Shipping & Handling
TOTAL:
ALLOW 4-6 WEEKS FOR DELIVERY

MAIL OR FAX TO:
Vida Klocke    706 Grant Place    Underwood, ND 58576
701-442-3478 (phone/fax)
e-mail vidaklocke@gmail.com

All you need to do is print out the form above and fill it in, or fill it in on screen and print it out. Enclose a personal check, money order, or enter your credit card information in the indicated areas. Please do not forget to sign the form for credit card approval.