Date: ___________________________________


Send me ________ pillows  at $_________ each 

Prices:                                                                                    Angel Wings® ................$19.95 each
10 - 19 pillows ..................10.75 each
20+ pillows ........................9.75 each

 Total Price. . . . . .$____________                                                                                

 Add Shipping and Handling:

 S/H . . . . . .  $_______________

□ COD. . . . .  $     4.50          

Grand Total . . . . $ ______________                                              

1 Pillow ...........................$ 3.00
2-4 Pillows .........................5.00
5-6 Pillows .........................6.00
10-19 Pillows ......................9.95
20+ Pillows .......................10.00

S/H prices are for the continental United States.

Name: _______________________________________________________________

Business: _____________________________________________________________

Address:_______________________________________________________________

City:     _________________________________________________________________

State:  _____________   Zip:  ______________

Phone: _________________________________

Fax:  ___________________________________

Email address: __________________________________________________________

Charge order by Mail, Fax, or Phone:

Select:   £ Mastercard

                £ Visa

                £ American Express

Card #_____________________________________ Exp. Date _______

Signature: _________________________________________________