MARIPOSA MAIL ORDERING FORM

Mariposa Herbs & Gifts
123 Bridge St., Las Vegas, NM 87701
(505)454-9240
dale@mariposaherbs.com [ ] Payment Enclosed (personal check)
Amount: $________
(see Grand Total Due)

[ ] Credit Card [ ] C.O.D. (see C.O.D. charge)

Visa Mastercard

American Express

Name:
Mailing Address:

Delivery Address:

Day Phone: ( ) Credit Card
Number:

Expires: Mo._______ Yr._______

Signature:

Item Name Quantity Price Total

$ $

$ $

$ $

$ $

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$ $

$ $

$ $

$ $

$ $

$ $

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Shipping and Handling Charges:
Up to $10.00.......$3.00 $40.01–$50.00....$5.00
$10.01–$20.00....$3.50 $50.01–$75.00....$5.50
$20.01–$30.00....$4.00 $75.01–$100.00..$6.00
$30.01–$40.00....$4.50 Over $100.00......$7.00
For C.O.D. orders, please add $3.50. Sub Total $

Shipping & Handling $

C.O.D. Charge $

Grand Total Due $

Item Name	Quantity	Price	Total
		$	$
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		$	$
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*Shipping and Handling Charges:* Up to $10.00.......$3.00 $40.01–$50.00....$5.00 $10.01–$20.00....$3.50 $50.01–$75.00....$5.50 $20.01–$30.00....$4.00 $75.01–$100.00..$6.00 $30.01–$40.00....$4.50 Over $100.00......$7.00 For C.O.D. orders, please add $3.50.	Sub Total		$
	Shipping & Handling		$
	C.O.D. Charge		$
	Grand Total Due		$