PLEASE PRINT THIS FORM FROM YOUR PRINTER & FILL OUT BY HAND
CORY COSMETICS SAMPLE ORDER FORM *THIS FORM FOR MAIL ORDER ONLY*
PLEASE PRINT	
 	 	 	 	 
NAME :	__________________________________________________

ADDRESS:  ________________________________________________

CITY, STATE, ZIP:  _______________________________________	 

EMAIL ADDRESS:  (If you'd like email notification of shipment)
__________________________________________________________
	 	 	 
FORM OF PAYMENT:	 	 	 	 
(   )  CHECK	(   )  MONEY ORDER	(    )  CASH			 
 	 	 	 	 	 
WANT TO USE CREDIT CARD? CHECK OUT MY SECURE WEB	 	 
PAYMENTS @ WWW.CORYCOSMETICS.COM

Please refer to website for proper names to list as we do not have a printed catalog.
		www.corycosmetics.com 

PLEASE NOTE: ALL SAMPLE SIZES ARE $0.35 EACH & THERE IS NO LIMIT ON THE AMOUNT .. SO
ORDER AS MANY AS YOU LIKE

SAMPLE NAME				QUANITY		PRICE EACH	TOTAL

___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______
___________________________________	_______		   .35		_______

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 payable to: Cory Timmermans 

SEND PAYMENTS AND THIS COMPLETED FORM TO:  	Cory Cosmetics
						c/o Cory Timmermans
						105 S Center St
						Heber Springs, AR 72543