Mail with payment (or card info) to:
PROUD REBEL
POB 100
FALKVILLE AL 35622
Proud Rebel Mail Order Form
(or order by phone 256_751_0175)
http://www.proudrebel.com
Email: sales@proudshopper.com

Date:____/____/20___

Page: ___ of ___

Name: ____________________________
Street: ____________________________
City: ______________ State:__ Zip:______
Mail to (if different): ______________________
Street: ______________________________
City:_______________ State:___ Zip:______
Phone: ____ - ____ - ______ Ext. _____
Fax: _____ - _____ - _______
Email: _____________@____________
Credit Card Option: ______ ______ ______ ______
Card Expires: _____/_____ and 3-digit code:_____
Billing address ZIP code MUST match card ZIP.
ITEM DESCRIPTION
Item numbers not used. Include sizes when required.
QTY COST
EACH
COST
TOTAL
1 . . . .
2 . . . .
3 . . . .
4 . . . .
6 . . . .
7 . . . .
8 . . . .
9 . . . .
10 . . . .
. SUBTOTAL $
Include 4% sales tax ONLY for deliveries INSIDE ALABAMA TAX $
Plus $7 flat-rate for shipping for the ENTIRE order. (No BS "handling charge"!) SHIPPING $
Money order or official check preferred. Other checks held for 10 DAYS.
Delivery is 7 days AFTER payment or 14 days for t-shirts.
Refunds for returns require salable condition. 20% restock fee or 40% for t-shirts.
TOTAL $