| Date: | Email: | Phone: FAX: | ||
| Bill To: (Name & address on credit card statement)) | Ship to: (If different than "Bill To") | |||
|
| Missouri state residents ONLY: Please add 6.6% sales tax. |
|
The
ESCAPE Co.
|
|
| Credit Card: q Visa qMaster Card qAmerican Express qDiscover |
| Credit
Card or gift certificate #: Expiration Date: |
| Signature: |
| If your U.S. order totals | Shipping Cost is |
| $0.01 to $49.99 |
$4.95 |
| $50.00 to $99.99 |
$6.95 |
| $100.00 to $199.99 |
$8.75 |
| $200.00 to $299.99 |
$10.75 |
| $300.00 and over |
$15.75 |