Mail completed form with payment to:
PROUD REBEL
POB 100
FALKVILLE AL 35622
Proud Rebel Mail Order Form
Best printed "to fit" in LANDSCAPE orientation
http://www.proudrebel.com Email: seller@proudrebel.com

Date:____/____/ 20___

Page: ___ of ___

Buyer Name: _______________________
Street: ____________________________
City: _______________ State:___ Zip:_______
Ship to (if different): ______________________
Street: ______________________________
City:_______________ State:___ Zip:_______
Phone: ____ - ____ - ______ Ext. _____
Fax: _____ - _____ - _______
Email: _______________@__________
Buyer address MUST match card billing address.
Credit Card no.: _____-_____-_____-_____
Name on card:_______________________
Expires:___/____ 3-digit code on back:____
ITEM DESCRIPTION (no item number needed, be sure to list sizes) QTY $ EACH $ TOTAL
1 . . . .
2 . . . .
3 . . . .
4 . . . .
5 . . . .
6 . . . .
7 . . . .
8 . . . .
9 . . . .
10 . . . .
. SUBTOTAL $
Alabama deliveries include 7% sales tax SALES TAX $
Include $6 for Priority shipping
(Express not available for mailorder)
SHIPPING $
Money Orders are not delayed but checks are held for 10 days to verify clearing.
Allow up to 3 weeks for non-Express delivery. No Express orders by check!
TOTAL $