GUILDCRAFT, INC.

401 South Sherman Street • York, PA 17403-2492

FAX (717) 846-8923 • PHONE (717) 854-3888

Customer Name:___________________________________________

Customer Address:_________________________________________

Customer City, State, Zip:____________________________________

VISA / MASTER CARD / DISCOVER ACCEPTED

CARD NUMBER: ____________ ___________ ____________ ___________

CARD EXP DATE: _________/________

NAME AS IT APPEARS ON CARD (printed):__________________________

SIGNATURE OF CARD HOLDER: __________________________________

Your Credit Card will be billed $99.00 for each chair shipped within the continental US.

(plus 6% sales tax for each chair shipped within Pennsylvania.)

•••••••••••••••••••••••••••••••••• SHIP JUVENILE CHAIR TO ••••••••••••••••••••••••••••••••••••

Quantity: _____

Name: ________________________________________________

Address: ______________________________________________

City, State, Zip: ________________________________________

••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

if additional items required please follow format on additional pages...