Please print and use this form for your orders. Sorry, this is NOT an ON-LINE Form, so you will need to print this out for processing.
Mail the completed order form to:                                    Or FAX the completed form to:
L. S. Rhoads                                                                               607-729-5486
P. O. Box 554                                                                     (Note: this is a secure fax not a shared machine!)
Johnson City, NY 13790-0554

Billing Address: (this must match billing address for card)	Ship to: (if different than ordered by for check or money order)
Name:	Name:
Address:	Address:
City, State, Zip:	City, State, Zip:
Phone/E-mail:	Phone/E-mail:

QUANTITY	STYLE #	SOLE	COLOR	SIZE (from Chart)	PRICE

CARD TYPE  (circle one)       VISA       MC  AMERICAN EXPRESS           DISCOVER

Card number

Exp date (mm/yy)

Signature