B Independent, Inc.

14720 S. Seminole Dr.

Olathe, Ks 66062

FAX: 913-390-7090
Billing Address    Ship to (if different from Bill to)

Name__________________________

Street Address___________________

City____________________________

State______________ Zip _________

Phone  (      ) ___________________

Name___________________________

Street Address____________________

City_____________________________

State______________ Zip __________

Phone  (      ) ____________________

 

Item # Qty Item Name Size Color Price Price Total
             
             
             
             
             

Payment Method

 
 Check or money order (please enclose)

Charge to:
 
MasterCard
 
Visa
 
American Express

Account #

                               
Expiration (mm/yy):
       

Phone # (     ) ____-____________

E-mail ______________________

____________________________

Signature ____________________

Name (printed) _______________
Merchandise total 
8.25% Sales tax (Texas only) 
Regular shipping/handling 
Extra shipping for oversized items 
TOTAL  

 

Thank you 

for ordering!
 
 

 $9.95   
 
 

        Note/comment: