Complete Form and Fax or Mail to:
ScribbidyScrubs.com
347 Woodland Rd.
Cairo, GA 39827
Phone: 1-850-491-1653
Fax: 1-404-393-9455

Bill To:

Ship To:

Name:  

Name:  

Address:  

Address:  

City:  

State:  

Zip:  

City:  

State:  

Zip:  

Phone:  

Phone:  

e-mail address (needed for order/shipping confirmation):  

item #

color

size

qty.

item description

price each

total price

Shipping & Handling (see chart below):                    

Order Subtotal:                    

Sales Tax - Georgia Residents Add 7%:                    

Gift Certificate Number:                                                  Subtract Gift Cert. Value:                    

Internal Code: Fax or Mail                                          Your Order Total Due:                    

Shipping Method (check one)       __ U.S.A.       __ International

U.S.A. Order Amount
$0.00 to $11.99 =
$12.00 to $24.99 =
$25.00 to $44.99 =
$45.00 to $59.99 =
$60.00 to $99.99 =
$100.00 to $199.99 =
$200.00 to $999.99 =
$1000.00 to 1499.00 =
$1500.00 & up =

U.S.A. Shipping Cost
$5.74 (+ .30¢ per item)
$6.99 (+ .30¢ per item)
$8.49 (+ .30¢ per item)
$9.49 (+ .30¢ per item)
$9.99 (+ .30¢ per item)
$10.99 (+ .30¢ per item)
$16.99 (+ .30¢ per item)
$38.99 (+ .30¢ per item)
$78.99 (+ .30¢ per item)

Intl. Order Amount
$0.00 to $14.99 =
$15.00 to $49.99 =
$50.00 to $99.99 =
$100.00 to $149.99 =
$150.00 to $199.99 =
$200.00 to $349.99 =
$350.00 to $499.99 =
$500.00 to $999.99 =
$1000.00 up =

Intl. Shipping Cost
$22.49 (+ $10 per item)
$31.49 (+ $10 per item)
$34.49 (+ $10 per item)
$41.49 (+ $10 per item)
$45.49 (+ $10 per item)
$61.49 (+ $10 per item)
$68.49 (+ $10 per item)
$75.49 (+ $10 per item)
$96.49 (+ $10 per item)

Payment Method. Sorry, no CODs. (check one)
__Check or Money Order (Payable to ScribbidyScrubs.com)    
__Visa    __MasterCard     __American Express     __Discover

Print Name on Credit Card:  

Credit Card Number:                               Last 3 digits on back of card (CID):

Expiration Date:  

Signature:  

Today's date: