collectorscorner.org store: Printable Coin Supply Order Form: REV.-1/1/2008

PLEASE PRINT ---- SHIPPING ADDRESS:_E-Mail Address: _____________@_____________________

NAME:_______________________________________________

ADDRESS:____________________________________________

CITY:_______________________STATE:___________________ZIP:__________________
ITEM NUMBER DESCRIPTION QUANTITY PRICE@
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SUB-TOTAL___________
Special: take 5% off of your order here ___________
New Jersey Residents Only, please add 7% sales tax on all orders ___________
SHIPPING & HANDLING ( All orders see below ) ___________
All QUARTER MAP & LARGE OAK FRAME ORDERS: (Weight & Oversized) Add EXTRA $2.00___________
OUT of U.S.A. Add EXTRA (Canada $20.00) Over Seas ($50.00) un-used postage will be returned___________
( _ ) Pay-Pal - - ( _ ) Cash - - ( _ ) Check - - ( _ ) Money Order--( _ ) Credit Card
( _ ) Visa ( _ ) Master Card ( _ ) Amer. Express - Credit Card # _______-_______-_______-_______,
exp date: _____/_____, security code: _____, Signature:____________________________________
U.S. FUNDS ONLY: Thank You
TOTAL INCLOSED_______________

SHIPPING & HANDLING
0 to $3.99 add $2.75
$4.00 to $9.99 add $4.50
$10.00 to $16.99 add $6.50
$17.00 to $24.99 add $8.50
$25.00 to $34.99 add $9.50
$35.00 to $49.99 add $10.50
$50.00 and up add $12.50
MAP & LARGE OAK FRAME ORDERS: Add EXTRA $2.00
Checks/MO payable to: Disk Works of South Jersey
MAIL TO: Disk Works of South Jersey
187 Clayton-Aura Road
Glassboro, New Jersey 08028-3404
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