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SHIP TO:
Name:
___________________________________ Telephone: __________________________________ (For
order ?'s ONLY!)
Address:
___________________________________
___________________________________
Item
name Size/Color
Combos Quantity Price Each TOTAL
_____________________ _________________
______ _________ ____________
_____________________ _________________
______ _________ ____________
_____________________ _________________
______ _________ ____________
_____________________ _________________
______ _________ ____________
Total Order
(please use this amount to calculate shipping fees):
$ ___________
Connecticut
Residents:
Please add 6% State Sales Tax here
+ ___________
Shipping*: Order up to $9.99 Add $3.50 shipping
Order $10.00 - $34.99 Add $5.50
shipping
Order $35.00 - $59.99 Add $7.50
shipping
Order $60.00 and up
FREE shipping!
+ ___________
I’m “rounding up” to help Shelton get
his surgery! Donation amount:
+ ___________
GRAND
TOTAL
=
$ ___________
Make checks
payable to: FACT Credit
Cards accepted: MasterCard or Visa
Card #:
____________________________ Exp. Date: _____ Signature:
__________________________
Mail to:
FACT, Inc.
Questions? Call 860.247.1275
Hartford, CT 06106-3838
Yes, you can order via Paypal! Use the above e-mail address.
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