Please print this form and mail or fax to:

Denise Patchell-Olson
P.O. Box 340
Dublin, NH 03444		 603.563.8868 (Phone)
603.563.7083 (FAX)
denise@patchell-olson.com (E-mail)


Ordered By:
Shipping Address
(if different):
Name

Name
Address

 Address
City

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E-mail
METHOD OF PAYMENT:
_____ Personal Check  _____ Visa  _____ Master Card
(Make checks payable to: DENISE PATCHELL-OLSON)

Card Number:


Expiration Date: ___________

Signature: ____________________________________


NAME OF PRINT YOU ARE ORDERING:
#1

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#2

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