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SHIP TO:
Name________________________________________________________________________
Address _____________________________________________________________________
City____________________________ State______________________ Zip________________
Phone #_____________________________
Method of Payment:
- Check No. __________
- Credit Card VISA
____M/C ____Disc ____AMEX____ Number__________________________________
Expiration Date_________________Authorized
Signature____________________________________
Print this form and fax to (610) 370-0548
or send to:
Leather & Silver by Maxwell
2457 Perkiomen Ave.
Reading, PA 19606
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