PLEASE PRINT THIS FORM FROM YOUR PRINTER

CORY COSMETICS MAIL ORDER FORM * THIS FORM FOR MAIL ORDER ONLY*

PLEASE PRINT
		
NAME: _____________________________________________________
 
ADDRESS:  _________________________________________________

CITY, STATE, ZIP: _________________________________________
 
EMAIL:  ___________________________________________	 

FORM OF PAYMENT:		
O  CHECK	 	O MONEY ORDER		O  CASH

WANT TO USE CREDIT CARD? CHECK OUT MY SECURE WEB PAYMENTS @ www.corycosmetics.com

PLEASE REFER TO WEBSITE FOR PRICING & DESCRIPTIONS. WE DO NOT HAVE A PRINTED
CATALOG.
 
QUANITY		ITEM DESCRIPTION				AMOUNT
_______		___________________________________		_________
_______		___________________________________		_________
_______		___________________________________		_________
_______		___________________________________		_________
_______		___________________________________		_________
_______		___________________________________		_________
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_______		___________________________________		_________

PLEASE FEEL FREE TO CONTINUE ON BACK OF PAGE IF NEEDED ...  	 
 	 	 
 			SHIPPING RATES		
 			$0.00 TO $9.99   - $4.80
 			$10.00 TO $49.99 - $7.70
 			OVER $50.00      - FREE
 	
 	 				SUB TOTAL	______________
		
		TOTAL FROM OTHER PAGES (IF NEEDED) 	______________
				
				SHIPPING & HANDLING 	______________
 		
 	 				ORDER TOTAL	______________
	 	 
PLEASE MAKE YOUR PAYMENTS OUT TO:  CORY TIMMERMANS
 	
SEND PAYMENTS AND THIS COMPLETED FORM TO:  	Cory Cosmetics
						c/o Cory Timmermans
						105 S Center St
						Heber Springs, AR 72543