Stain Remover order form

__________

S & H: (please call for rates - 877.531.1517):

__________

Home - or -

Sales Tax: (OH & KY add 7%):

__________

Use this form to submit orders for delivery within the Continental US only! Pricing is subject to change without notice.

Remit this amount:

$ ________

Miller Bros. Paint & Decorating ~ Since 1910 ~

order date:______ / ______ / __________

	fill in SHIP TO to if different than below		complete only if necessary

bill to:	__________________________	ship to:	__________________________
address:	__________________________	address	__________________________
city:	__________________________	address	__________________________
st/zip:	__________________________	city:	__________________________
e-mail:	____________@____________	st/zip:	__________________________
phone:	( ) ________ - _________	phone:	( ) ________ - _________


Please indicate Credit Card payment preference:
Amex Visa MC Discover		Money Order
credit card #

Money Order payable to: Miller Bros. Paint

expiration date:

month

year

cardholders signature:

Defy Products

shipping & handling charges:

Fax or Mail completed forms to:

(513) 458-5060

Miller Bros. Wallpaper Co., Inc.
PO Box 12210
4343 Montgomery Rd
Cincinnati, OH 45212-0210