SERVANT QUARTERS
P.O. Box 219
Cathedral City, CA 92235
Office: 1 (760) 321-0077
Toll Free Order: 1 (888) 321-0077
Fax: 1 (760) 202-1139


Please Print Clearly, Thank You !
I WISH TO ORDER:

Item #: _____ Description: ___________________ Quantity ____ Size: _____ Price: $_______

Item #: _____ Description: ___________________ Quantity ____ Size: _____ Price: $_______

Item #: _____ Description: ___________________ Quantity ____ Size: _____ Price: $_______

Item #: _____ Description: ___________________ Quantity ____ Size: _____ Price: $_______

Item #: _____ Description: ___________________ Quantity ____ Size: _____ Price: $_______

Total Amount Of My Order Is: $__________________


PAYMENT:

VISA: ___ Mastercard: ___ Discover: ___ American Express: ___ Check:___ Please Bill Me: ___

Name On Credit Card: __________________________ Signature: ________________________

Credit Card Number:________________________________ Expiration Date:________________



MAIL ITEMS TO:

Name:_______________________________________________________

Address:____________________________________________________

City:________________________________________________________

State:__________ ZIP:__________________

Phone: (______) ________________________



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