Billing Information
Name (Please Print) __________________________________________________________

Address: ______________________________________________________________________

City: ____________________________ State_________ Zip__________________ Country: US

Phone: __________________________________________ Fax: _______________________

Email: ______________________________________________________________________

Payment Information
Credit Card Type: ____________________________________________________________

Card Number: ____________________________________________________ Exp: _________

Ship to billing address?

Shipping if Different Than Billing
Name (Please Print) __________________________________________________________

Address: ___________________________________________________________________

City: ____________________________ State_________ Zip__________________ Country: US

Furniture Selection 1
Name: ___________________________ Item #: _______________

Unit Price: ________________________ Quantity: ______________

Furniture Selection 2
Name: ___________________________ Item #: _______________

Unit Price: ________________________ Quantity: ______________

Furniture Selection 3
Name: ___________________________ Item #: _______________

Unit Price: ________________________ Quantity: ______________
Furniture Selection 4

Name: ___________________________ Item #: _______________

Unit Price: ________________________ Quantity: ______________