| Name: ____________________________________________________ | |
| Mailing Address: _____________________________________________ | |
| ___________________________________________________________ | |
| City, State & Zip: ____________________________________________ | |
| Phone: ____________________ | |
| Email: ____________________________________ | |
| I would like to order the following items: | |
| ______________________________________________ | $_________ |
| ______________________________________________ | $_________ |
| ______________________________________________ | $_________ |
| ______________________________________________ | $_________ |
| ______________________________________________ | $_________ |
| Choose one of the following postal charges: | |
| Up to 2 molds | $ 11.00 |
| 3 or more molds | $13.00 |
| 4 molds or more - free shipping (USA Only) | $ 0.00 |
| International - one mold/sometimes two | $48.00 |
| International - 2 - 3 molds | $59.00 |
| International - more than 3 molds, please email for quote | |
| Payment Type: | |
| Mastercard or Visa | |
| Credit Card Number: _________________________ | |
| Expiration Date: ______________________________ | |
| Name and Address if different than the shipping address. | |
| __________________________________________________________ | |
| __________________________________________________________ | |
| __________________________________________________________ | |
| I do take Bank of America personal checks, money orders
or certified checks, which can be made out to Regina Edmonds or White
Gothic Studios and sent to 4890 NW 13th Terrace, Pompano Beach, FL
33064 Phone: 954-420-5120 |
|
| You can also pay via paypal. Sent payment to regina@whitegothic.com | |