| For photos, refer to the
Bicycle page when making choices for this form. Call
(715)455-1652 for custom color or fabric information. |
| Bicycle Seat Saver
Cushion |
Quantity |
Item Price |
Total Price |
| _______ |
$20.00 |
$_________ |
| Top Fabric Choices - Circle or highlight color choice |
Faux Sheep 1.Black 2.Gold 3.Natural
("natural" is
a polar fleece with sheep texture)
|
Faux
Leopard Skin1.Blk/Brn/Crm
multi
|
Faux Butter Suede (fuzzy)1.Black
2.Dark
Brown 3.Brown
4.Gold
(pale)
|
| Polar Fleece Tie Dye 1.Bright
multi (red, pink, yellow, blue, green, gold, purple) |
| Polar Fleece Solids 1.Black
2.Charcoal
Gray 3.Heather
Gray 4.Royal
Blue 5.Purple 6.Burgandy
7.Fuschia 8.Barn
Red 9.Forest
Green |
Special Instructions:
How did you find us? |
Sub Total |
$_________ |
| Wisconsin Sales Tax (Wisconsin residents only) |
5.5% |
$_________ |
| Shipping up to $60 |
$5.95 |
$_________ |
| Shipping $60 to $120 |
$7.95 |
$_________ |
| Shipping over $120 |
Free |
$_________ |
| Total Amount Due |
$_________ |
Credit Card Type (circle one): Visa, MC, AmEx,
Disc
Credit Card # __________-__________-__________-__________
Expiration Date__________ Security Code (3 digits on back)__________(or
4 digits on front by signature)______________
Name on Card
|
|
|
|
Name ___________________________________________________Date_________________________ |
|
Address ______________________________________________________________________________ |
|
City________________________________________ State ________ Zip
Code _________ |
| |
| Phone_________________________Email_________________________________________ |
mail: byGayle
N14397 380th Street
Ridgeland, WI 54763 USA
We will accept your payment with VISA, Master Card, American Express,
or Discover by phone or on the WEB, check, money order or
credit card by mail. Email:gayle@bygayle.com Phone:1(715)455-1652 |