*Mystique Vintage Order Form* Date:___________ Your Name:____________________________ Address:_______________________________ City:_______________________________ State:_______ Zip: ________________ Tel. #___________________ Email:___________________ Item # Quantity Price Ea. Sub-Total        $              $              $              $              $              $              $       Total      Note(s) -------------------- Cut here and retain lower part for your records --------------------------- ORDERING INSTRUCTIONS To order by U.S. mail, please print this form, fill in the required information and mail with check or money order made out to: Karen Broshears, and mail to: Karen Broshears 27 Bushwick Place Springfield, MA 01109 Order sent on:___________________ Items ordered:_________________________ _______________________________________ Amount spent:__________________________ Print this page.