[LIGHTHOUSE STORE] 

ORDER FORM

Item Name Stock Number Quantity Price Total
         
         
         
         
         
         
Shipping and Handling:

Up to $15.00

 $4.00

$15.01 - $30.00

 $5.00

$30.01 - $50.00

 $6.00

Over $50.00

 $7.00
SUB TOTAL  
S & H  
ORDER TOTAL  

 

NAME (s):  ___________________________________TELEPHONE: (______)____________

ADDRESS:  ___________________________________________________________________

CITY:  _____________________________  STATE: ________________  ZIP: ____________

 

Enclosed is my check or I have indicated my credit card payment choice below.

            VISA or MasterCard Credit Card # _____________________________________________

            Expiration Date: ____________

Please Mail to: Friends of Seguin Island
                          72 Front Street, Suite 3
                          Bath, Maine 04530

Thank you very much for your support.