Please print this form and mail or fax it for a 10% discount to
Heart & Hand Dry Goods Co.
3011 Hamilton Blvd
Sioux City, IA 51104
Fax: 712-258-3161

Name:___________________________________________________________________

Address:_________________________________________________________________

City:_________________________State:___________ZIP:_________________________

Phone: (_____)____________________________________________________________

Payment Enclosed:__________VISA:_________Master Card:________________________

Account #:____________________________Expiration Date:_______________________

Name on "Charge Account":___________________________________________________

Signature (for charge accounts only):____________________________________________

Qty. Description Price/Item Total

SHIPPING CHARGES Orders up to $15 add $ 3.50 Orders up to $25 add $ 5.00 Orders up to $50 add $ 6.00 Orders over $50 add $ 7.50 Subtotal: _____________________________ S&H (from Chart)_______________________ In Iowa add 7% tax: ____________________ TOTAL: ______________________________