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Total |
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| Subtotal |
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| Illinois Residents add 6.25% tax |
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| Grand Total |
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Ship To:
Name:___________________________
Address:___________________________________
City:_____________________________
State:_________________Zip:________
Phone:___________________________
Email Address: ________________________________
Bill To (if paying by credit card, this should be the address where the bill is sent):
Name:___________________________
Address:___________________________________
City:_______________________
State:_________________Zip:________
Phone:___________________________
Email Address: ________________________________
CREDIT CARD AUTHORIZATION:
[__] Visa [__] MasterCard [__] Discover [__] American Express
Card Number: ____________________________
CVV Code (3 digit number on back of card): ______________
Card Holders Name as it appears on the card: ______________________________________
Expiration Date: ____________
Card Holders Signature: ____________________________________________
Please send Certified Checks or Money Orders, payable in U.S. Funds to:
SI Enterprises
1121 S. Roosevelt
Harrisburg, Illinois 62946
When paying with a Money Order or Certified Check,
please allow time for funds to be deposited and cleared.
You may call (618) 841-1580 to order or if you have any questions.
You may fax your order to (618) 253-3198.
