PINE SPRINGS POTTERY 1650 STONEY ROAD NEW BETHLEHEM, PA 16242
| CUSTOMER INFORMATION |
| Ordered By: |
| Street, City, ST Zip: |
| Phone: e-mail: |
| Payment Method: Check# Money Order |
| SHIP TO (if different from above) |
| Name: |
| Street, City, Zip: |
| Phone: e-mail: |
| QUANTITY | ITEM | PATTERN | PRICE EACH | TOTAL |
| SHIPPING TO ZIP CODES | 00000-30000 | 30001-60000 | 60001-99999 |
| Total $ of Order before Tax | |||
| Up to $30.00 | $ 9.00 | $10.00 | $13.00 |
| $30.01 - $50.00 | $10.00 | $12.00 | $15.00 |
| $50.01 - $75.00 | $11.00 | $14.00 | $17.00 |
| $75.01 - $100.00 | $13.00 | $16.00 | $19.00 |
| $100.01-$150.00 | $15.00 | $18.00 | $21.00 |
| $150.01 - $200.00 | $17.00 | $20.00 | $23.00 |
| Subtotal | |
| 6%Tax (PA Orders) | |
| Shipping | |
| Total |
Over $200.01 Please contact me for shipping rates. e-mail: mlewis@pinespringspottery .com phone: (814) 764-5626
NOTES OR SPECIAL INSTRUCTIONS ON BACK - CHECK HERE ____