Print and Fax to: 860-399-4726
Mail to: The Shoe Shine Kit, 4 Center Road, Unit 10, Old Saybrook, CT 06475
Phone: 860 510 0849 Weekdays -------------- Email: Cobble@snet.net

SHIPPING Address:

Name:______________________________ Address:_____________________________

City:_______________________ST____ Zip Code_______________

Phone:______________________Email:__________________________________

BILLING Address( if not the same):
Name:______________________________Address:_________________________

City:_______________________ST_____Zip Code________________

Phone:______________________Email:___________________________________


ITEM NAME Color or Size Quantity Price
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______________________________________ ___________ ____________ ____________
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Shipping Charges (please consult "info" page for shipping rates. $___________

If delivered within CT. please add 6% Sales Tax. $_______________

Total $__________

Check_________Money order___________
Paypal______________________________ (email address to be invoiced)
Master Card_______ Visa_______

Credit Card Number_______________________________________
Expiration Date_________ CVV # _______ ( Last three digits in the row of numbers on the signature side of card)