www.doxieholic.com
Doxieholic Mail Order Form
 
Quantity
Item No.
Color
Size
Item Name
Price
Total

Make checks payable to Doxieholic and mail to:
Doxieholic - 140 Stateline Road - Bowdon, GA 30108-2700

Subtotal
Shipping (from charts below)
Ga. Residents Add 7% Tax
Billing Address (on credit card account)
Shipping Address
Total
First Name*_____________________
Middle ________________________
Last Name* ______________________
Suffix __________________________
Address 1* _______________________
Address 2 ________________________
City* ___________________________
State/Province* ___________________
Zip Code* _______________________
Country* _______________________
Phone Number*___________________
Email*__________________________
First Name*_________________________
Middle _____________________________
Last Name* __________________________
Suffix ______________________________
Address 1* ___________________________
Address 2 ____________________________
City* _______________________________
State/Province* _______________________
Zip Code* ___________________________
Country* ____________________________
Phone Number*_______________________
Email*______________________________

Payment Type (Circle One)__Visa__ Mastercard__Discover__Check Enclosed
Credit Card Number: ____ ____ ____ ____
Expiration Date:___/___ Card Code______
Name on Card: ___________________________________
Signature: ___________________________________

* Required

Priority® Mail (2 to 3 days)
.01 to $24.99 = $6.50
$25.00 to $34.99 = $7.50
$35.00 to $54.99 = $8.50
$55.00 to $74.99 = $9.50
$75.00 to $99.99 = $10.50
$100.00 to $124.99 = $11.50
$125.00 to $149.99 = $12.50
$150.00 and up = $14.50
For insurance add $2.00