www.ddbrain.com  -  Order Form
Item No. Description Wt./Size Color/Code Quantity Price Ea. Total

Sub Total:

Add Shipping Charges. See Chart Below:

Overnight Delivery, Add $19.95:

State Sales Tax (if any):

Total Amount:

All items are shipped as quickly as possible.
Shipping and Handling for the Continential U.S.
Total Price of Items Standard Delivery 2nd Day Air
  Up to $50.00   $6.95   $11.95
  $50.01 - $100.00   $7.95   $12.95
  $100.01- $150.00   $8.95   $13.95
  $150.01 - $200.00   $9.95   $14.95
  Over $200.01   $10.95   $15.95
Customer Information
Name 
Address 
City 
State 
Zip Code  
Daytime Phone  
E-Mail Address 
Shipping Information - only if different from above address
Shipping Address  
City 
State 
Zip Code 

Payment Information

Card Name 
Card Number 
Expiration Date 
Cardholder's Name 
Special Instructions
Questions, Comments 
or Special Instructions 

 

 

 

Thank you for your order!

 

Form by Net Atlantic