Bernieland

Order Form

Please complete and print this form (or a facsimile thereof) to include with full payment for your order:

Your information

Name:
Street Address:
City:
State:
Zip Code:
Email Address:

Recipient's information (if different from your information above)

Name:
Street Address:
City:
State:
Zip Code:

Order and Payment information

Number of double CD-R sets of Arctic Green being ordered:
Payment of twenty U.S. dollars ($20) per set as
      Total value of enclosed cash:
      Total value of enclosed checks:
      Total value of enclosed money orders:

Payments are only accepted in U.S. dollars, or by check or money order (payable to "Bernard Karmilowicz") for same. A $30 fee will be assessed for each returned ("bounced") payment. Product is not shipped until payment clears.