Leila Cools Order with Check/Money Order

ULTIMATE DROP DOWN MENU v3.8.5 by Brothercake

vacation

If you would like to pay by check, money order, COD (within Canada), or Paypal, please list items and fill this form below. You will recieve a confirmation email with total.

Product Code/Name	Quantity	Product Code/Name	Quantity	Product Code/Name	Quantity


	Billing Address:	Shipping Address:
		(If different from billing address)
	Name:	Name:

	Company:	Company:
.
	Address:	Address:

	City:	City:

	State/Province:	State/Province:

	Country:	Country:

	Zip/Postal Code:	Zip/Postal Code:

	Phone:	Phone:

	Fax:	Email:


	Special Requests:	Retail Tax Number (for Canadian retailers).

.