Name :___________________________________Daytime Phone_________________
Address:__________________________________Evening Phone__________________
Address 2:_________________________________Cell Phone_________________
City:______________  State_______  Zip +4:______________
e-mail Address:________________________________________

Item Number	Color/Size	Description	Quanity	Price	Total

 Shipping Charges in U.S.A.                            Payment Method      Subtotal:________________    

Order Amount	Maximum Shipping*	(Circle One)		Coupons or Discounts:_______________
$29.99 or less	$7.00	Money Order		Sales Tax****:___________
$30.00 - $39.99	$8.00	Mastercard/Visa		Shipping:________________
$40.00 - $49.99	$9.00	Discover		Grand Total:_____________
$50.00 - $99.99	$10.00	American Express		Credit Card Number**
$100.00 -and over	10%	Check		________________________
Outside USA:	Email for estimated	PayPal***		Expiration Date    CSV Code
shipping or use a	Credit Card.			___________   ___________

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This form may be printed and reproduced as needed for Pillaged Village orders

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*On credit card orders, actual shipping will be charged, never more than the maximum from the chart above.
**Credit card billing address must match billing address. If you wish us to ship to a different address,
please provide credit card billing address in addition to shipping address.
***For PayPal, send payment to "pvsales at pillagedvillage dot com"  
****(Ohio Residents Only) add 7.5% Sales Tax

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Mail orders to: The Pillaged Village                                   Our Toll Free Ordering Number
                              31E Eagle Court                                              (877)793-1066
                             Carlisle, OH 45005-6325                        Email us: "pvsales at pillagedvillage dot com"
Orders may be Faxed to (937)743-0697