Rebel Gals
901 Jewell Avenue
Portsmouth VA 23701-1911
Phone / Fax 757 488-4804
901 Jewell Avenue
Portsmouth VA 23701-
Phone / Fax 757 488-
Web site:
http://www.nkclifton.com/rebelgals/rebelgals.html
E-mail: chatykat@infionline.net
E-
Customer Order Form
Make Checks and Money Orders payable to:
Katherine W. Clifton
Method of Payment (Please circle one )
Check
Cashiers Check
Money Order
Check
Cashiers Check
Money Order
Name: ___________________________________________
Address: _________________________________________
City: ____________________________________________
State: ________________ Zip Code: _________________
Phone: __________________________________________
* Tax for Virginia
residents, only
Up to $50.00
$12.00
$50.00 to $99.00
$18.00
$100 to $199
$21.00
$200 to $399
$24.00
$400 to $599
$27.00
Over $600
Please Call
Qty.
Item Numb.
Item Name
Color
Price Each
Total Price
Total Order
VA Sales Tax 5%
18% If Oversize
Shipping & H
Grand Total
Shipping, Handling &
Insurance Charges
Insurance Charges
For Rebel Gals Use Only
Received:
Amount received & verified:
Filled: Shipped:
Completed :
Back ordered:
Amount received & verified:
Filled: Shipped:
Completed :
Back ordered:
Check our web site
frequently to see new items
Kathy and Peggy
Kathy and Peggy
We thank you for your order