Complete this form and Print, then Fax or Mail
 
Name:          
Address:       
City:          
State:         
Zip Code:      
Phone Number:  
Fax  Number:   
Email Address: 
PLEASE ENTER HOW MANY PAIRS YOU WISH TO ORDER
$49.95 + $5.00 S/H = $54.95/pair (Please total below)
Total  $

Paying by Credit Card
Pay by Credit Card Card: Amount to Charge $
Card Number:  Expiration Date: 
Name as it appears on the card: 

FAX TO: 1-615-228-1301


Paying by check:
Make your check payable to Blevins, Inc. and mail w/completed form to: 
Andy Oliphant
Blevins, Inc.
421 Hart Lane
Nashville, TN  37216
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