Jax & Company's Jewelry Order Form

Jax & Company
Black Hills Gold & Southwestern Jewelry
P.O. Box 564
Ashland, OH 44805-0564
Phone: 1.419.557.2808 (9 a.m.- 6 p.m. EST Mon.-Fri.)
sales@jaxworld.com | http://www.jaxworld.com

ORDER FORM
ALL COSTS ARE USD (U.S. DOLLARS)

Item #	Description	Size	Stone/ Color	How Many	Cost Each	Total Cost
#	`	`	`	`	$	$
#	`	`	`	`	$	$
#	`	`	`	`	$	$
#	`	`	`	`	$	$
#	`	`	`	`	$	$
#	`	`	`	`	$	$
#	`	`	`	`	$	$
#	`	`	`	`	$	$
Subtotal						$

Priority Mail w/delivery confirmation and insurance for U.S.-bound orders : Add $8.00						$
Express Mail w/tracking and insurance for U.S.-bound orders : Add $26.00						$

Ohio Residents: Add State and Local Sales Tax for your county						$
TOTAL COST						$

I wish to pay using [ circle one ] : Check | Money Order

CONTACT PH#: (________)_________-______________*

Billing Address Information

Name:  ______________________________________________________________________________

Address:  __________________________________________________________________________________________

City/Town:  ___________________________________________

State :    ________________________________________________

Zip Code :   ______________________________________________

E-mail Address:  ___________________________________________

Shipping Address

(if different from above)

Name:  ______________________________________________________________________________

Address:  ________________________________________________________________________________________

City/Town:  ___________________________________________

State :    __________________________________________________________________

Zip Code :   ______________________________________________

Additional Information/Instructions/Requests

(if any)

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