Mail To: Prairie Rose Jewelry 135 Country Center Drive STE B5-245 Pagosa Springs, CO 81147
Payment By	Check Money Order Credit Card
If Paying By Credit Card
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Card Type	American Express Master Card Visa Discover
Card Number
Expiration Date (mm/yy)
Sold To
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Address Cont.
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Telephone		Email
Ship To
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Address
Address Cont.
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Item Code Item Name Price Total Order 1 Order 2 Order 3 Order 4 Order 5 Order 6 Order 7 Order 8
	Sub-Total
	Shipping
	Total
Shipping	Standard ( $7.00 Priority Mail w/ Insurance ) Express Mail 2 Day ( $18.80 )
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