Friends of the Selinsgrove Community Library
SUSQUEHANNA UNIVERSITY
SESQUICENTENNIAL COMMEMORATIVE CROCK
MAIL ORDER FORM
Please print, complete & mail this web form
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Send mail orders to:
Bujno Pottery 257 West Main St. Adamstown, PA 19501 pottery@ptd.net
Please allow approximately 4 weeks
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Ordered by: PLEASE PRINT Name __________________________________________ Address _______________________________________ Address_________________________________________ City ___________________________________________ State ___________________________Zip_____________
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Ship to: (if different than “Ordered by”) PLEASE PRINT Name __________________________________________ Address ________________________________________ Address _______________________________________ City ___________________________________________ State ___________________________Zip_____________
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Daytime Phone (____) __________________
E-mail Address _____________________________________________________________ (for tracking & shipping information)
Crocks are $46 each (includes shipping)
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# Crocks Ordered
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Unit Price $46.00
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Total |
Thank you for your order!
METHOD OF PAYMENT:
5 Check or Money Order (make checks payable to Bujno Pottery)
Credit Card:
5 VISA 5 MasterCard 5 Discover 5 American Express
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Please list all digits from your credit card Expiration date: (mm/yy)
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Name on card (print)
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Signature