The Pampered Kitty – Order Form

Please print this form, fill out completely and send it to:

Jan Raffaele, 473 Queen Anne Road, Harwich, MA 02645

Questions: 774.237.0797

Your e-mail address is important, as it will be the first line of communication with you, if we have any questions regarding your order. We will not sell or rent your information to any other company without your permission.

ORDERED BY:

Name: ______________________________________________

Address:_____________________________________________

City, State, Zip: ________________________________________

Phone No. ____________________ E-mail: ___________________

Is this for a gift certificate? _______________

Ship to (if different than above):

Name: ________________________________________________

Address:_____________________________________________

City, State, Zip: ________________________________________

Phone No. ____________________ E-mail: ___________________

Description/Code                                Quantity      Price Each    Total

                                                                                                                                                                                                    Subtotal_________________

                                                              Massachusetts (only) Sales Tax 5%  _________________

                                                              Total __________________

PAYMENT OPTIONS:

Personal check (   )          Money Order (   )          Credit Card (   )

For payment by Credit Card:

MasterCard (   )            Visa (   )          Discover (   )           Am. Express (   )

Account # ________________________ Expiration Date: ___________

Name on Card ______________________________________________