EracismWear
11333 Moorpark St., #506
Toluca Lake, CA. 91602-2618

Order by phone 9 am - 5 pm Pacific Time
Call our toll-free number
1-888-Eracism
Order by snail mail or fax at 1-800-380-7111

Name

Address

Apt. or Sutie

City

 State Zip

Best Phone

 (555) 555-5555

Or Ship to:

 (Only if different from Ordered by)

Name

Address

Apt. or Suite

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Include gift message:
From:
Item Color Size Quantity Item Price Total
           
           
           
           
           
           
           
Shipping and Handling Charges for EACH Address:    
Purchase Amount: Add:  
 Up to $20.00  $5.50  
 $20.01 to $36.00  $6.50   Merchandise Subtotal  
 $36.01 to $42.00  $6.95   8.25% Sales Tax (CA only)  
 $42.01 to $50.00  $7.95   Alaska/Hawaiian orders OK  
 $50.01 to $66.00  $8.95   (Call for Pricing) Rush Delivery  
 $66.01 to $100.00  $9.95  Shipping & Handling (street address required)  
 $100.01 and over  $10.95   TOTAL  
Don’t Procrastinate – Order Now!

Make Checks Payable to: ERACISM Wear

Pay with: Check Money Order Visa MasterCard AMX Discover

Credit Card # Exp Date:
Last 3 numbers on back ; Last 4 numbers for AMX

Approval Signature _____________________________________________________________
Office Use Only
Date Recv’d Rep Chk#   Approx Ship Date Special Inst.