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

Date:____ / ____ / 2015

Page: ___ of ___

Buyer Name: _______________________
Street: ____________________________
City: _______________ State:___ Zip:_______
Ship to (if different): ______________________
Street: ______________________________
City:_______________ State:___ Zip:_______
Phone: ____ - ____ - ______ Ext. _____
Fax: _____ - _____ - _______
Email: _______________@__________
No Card Orders at this time
ITEM DESCRIPTION (Item numbers aren't used. Just descriptions. Be sure to include sizes if needed.) QTY $ EACH $ TOTAL
1 . . . .
2 . . . .
3 . . . .
4 . . . .
6 . . . .
7 . . . .
8 . . . .
9 . . . .
10 . . . .
. SUBTOTAL $
Include 7% sales tax ONLY to deliveries INSIDE ALABAMA SALES TAX $
Include $6 for shipping for the entire order SHIPPING $
Money orders, cashiers checks, and official checks are not delayed. But, personal checks must be held 10 days to clear. TOTAL $