Holy Originals ORDER FORM

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Please print out this page, complete it, and send by one of the following:

MAIL: 
Sedona Hummingbird Gallery
6560 State Route 179 Ste 126
Sedona, AZ 86351 USA 
TELEPHONE:  (928) 284-0339
     ***For Security Reasons, Do Not Send Credit Card info By E-Mail***

    Your Name: ____________________________________________________________
    Address: ______________________________________________________________
    Address: ______________________________________________________________
    City: _____________________ State/Prov.:______ ZIP/Postal Code __________ Country ______________
   Ship this order sent to me IMPORTANT:  In case of questions, how do I contact you?
Telephone:______________________________
E-Mail Address___________________________

   Ship this order to the person below
       Recipient's Name:  _______________________________________________________
       Address: ______________________________________________________________
       Address: ______________________________________________________________
       City: _____________________ State/Prov.:___________ ZIP/Postal Code ___________
             This gift is from: _________________________________

Payment Method (circle one):      Check      MoneyOrder              

Card Number: ______________________________________________ CVV  code _________ (3 digits on back of card)

Exp. Date: _________ Cardholder Name:_______________________________________
Merchandise Order:      

Product

Description

Qty.

Price

Total $
_______ _______________________________________ ____ _______ __________
_______ _______________________________________ ____ _______ __________
_______ _______________________________________ ____ _______ __________
_______ _______________________________________ ____ _______ __________
_______ _______________________________________ ____ _______ __________
_______ _______________________________________ ____ _______ __________
_______ _______________________________________ ____ _______ __________

GOODS TOTAL:

 __________

Add: Shipping

__________
Shipping charges (Priority Mail)

FINAL TOTAL

__________
             0 - $40.00
  $  40.01 -   70.00
  $  70.01 -   90.00
  $  90.01 - 120.00
  $120.00 - up		 $6.5
  7.50
  8.50
  9.70
Contact me		 If merchandise is to be shipped to more than one address, 
each shipment will carry a separate shipping charge.
Outside the US, first e-mail me for shipping costs.