Real Bodies Clothing from Bali Order Form Date: ___________

Billing Information

Name:

Address:

Address:

City: State: ZIP: Country:

Phone:

Email:

Shipping Information (ONLY NEEDED WHEN DIFFERENT FROM BILLING INFO)

Name:

Address:

Address:

City: State: ZIP: Country:

Phone:

Email:

Delivery Options

q Standard (USPS Priority) q Express (USPS Express) q Other:

Payment Information

q MasterCard q Visa q American Express q Discover q Other:

Card Number: oooo oooo oooo oooo

Amex: 4 digits on card front

Others: 3 digits on card back

Expiration: Month:oo Year:oo CVVoooo

Selection Information

Item	Description	1^st Fabric	2^nd Fabric	Size	Price	Qty	Total
					$		$
					$		$
					$		$
					$		$
					$		$

$0.00 - $99.99 $5.50

$100.00 - $199.99 $7.00

$200.00 - $299.99 $8.50

$300.00 - $399.99 $10.00

$400.00 - $499.99 $11.50 (and $1.50 for each additional $100)

Add $15.00 outside continental United States.

Add $15.00 plus $1.00 per garment for rush delivery.

Add $30.00 plus $2.00 per garment for rush delivery outside U.S.

Subtotal $

Shipping $

Total $