Mail Order Form

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{Please Print This Form & Fill it out}

Mail Order Form

Send to:

Smith Distributors

Owen Smith

P.O. Box 484

Clio, Michigan 48420

Make Payable To: Owen Smith

Payment Methods: Credit/Debit Cards, US Postal Service Money Order,

Personal Check ( Processing 2 weeks until it's cleared )

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Billing Information

Your purchase will be shipped to this address.

First Name:

Last Name:

Billing Address 1:

City:

State:

ZIP Code:

Country:

Card Type:

Credit Card Number:

Expiration Date:

Card Verification Number:

Email Address:

(On the back of your card, locate the final 3 digit number)

Home Telephone:

Signature (Print) Name: Date:

Sub Total:

California's Sale Tax 8.75%, Arizona's Sale Tax 5.6%, Michigan's Sale Tax 6%:

(Look at Shipping Chart) Shipping & Handling:

Total:

Shipping: Home Address 2:

Item # Quantity Description Price Total

Placing an Order Lists

# 1

# 2

# 3

# 4

# 5

# 6

# 7

# 8

# 9

# 10

Shipper: UPS & Canada Post Shipping Chart

United Parcel Service

Minimum Purchase Maximum Purchase Shipping

$0.01 $99.99 $7.50

$100.00 OVER FREE

Canada Post Parcel

Minimum Purchase Maximum Purchase Shipping

$0.01 $29.99 $20.00

$30.00 OVER (+) 45%