First Name: ______________ Last Name: __________________

Street Address: ________________________________________

City: ____________________ State: _______ Zip: ___________

Phone: __________________ Alt. Phone: __________________

Color: _________Special Instructions: _____________________

Salesperson: ______ Date Faxed: _______ Del’y. Date: _______

Length: ____ Width: ____ Skirt Height: ____ Radius/Cut: _____

Cost:    __________

Tax:     __________

Total:   __________

Deposit: _________

Balance: _________

P/U Date: ________

Paid Date: _______