Polly Paintbrush
"Outrageous Originals and Custom Designs"
Order Form
To order by phone 978-386-0059 or fax this form 978-386-7149
By Mail - Order Department
328 Erickson Road
Ashby MA 01431

Sold To : Ship To : (if different)
Name : Name :
Address : Address :
City : City :
State/Zip Code : State/Zip Code :
Daytime Phone : Daytime Phone :
Qty.
Size
Design Name
Description-Style
1st Color Choice
2nd Color Choice
Cost Ea
Total
               
               
               
               
               
               
               
               
               
               
               
Shipping & Handling PAID BY : (Check One)
Total Amount
                   
up to $15.99 $5.95 [   ]  Check Shipping Charge  
$16.00  -  $30.99 $6.95 [   ]  Money Order
Next/2nd Day Add $25.00/$20.00
 
$31.00  -  $40.99 $7.95 [   ]  Master Card
Glittering Add $5.00 per item
 		 
$41.00  -  $50.99 $8.95 [   ]  Visa Card
Foil Add $2.00 per item
 		 
$51.00  -  $75.99 $9.95 [   ]  Discover Card
XXL Sizes Add $1.50 per item
 
$76.00  -  $100.99 $10.95 Card No.
MA Add 5% Tax
  
over $101.00   10% Expiration Date : 
Gift Certificate (# __________ )
 
Federal Express Available   Signature
GRAND TOTAL
  

Economic conditions prevent us from guaranteeing prices as shown,
however, we will make every effort to maintain the prices as shown here on our Web Site.
Therefore, we reserve the right to bill at corrected prices.
Please note that we are unable to ship to international addresses at this time.