Bernina Patch------ Order Form
Mail to: Shop 1, 564 High St Penrith, N.S.W.
2750
Print this form out via your printer and complete the details and post or fax to
the address above with your cheque or money order (if not using charge card )
It is suggested that you set your page margins to Left 0.5
Right 0.5
| Surname:
First Name: |
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| Address:
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| Town/City:
State:
Post Code: |
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| Home Ph:( )
Bus/Mobile: |
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| Method of Payment: [ Mastercard] [Visa] [Bankcard] [Cheque] [Money Order] | |||
| Card No: [ ][ ][
][ ][ ][ ][ ][ ] [
][ ][ ][ ][ ][ ][
][ ] Expiry Date: /
/
Signature: |
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| Item | Qty | Price | Total |
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
| $ | $ | ||
|
$ | ||
|
Total | $ |
| Office use only:
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