PATCH PALS PRINT ORDER FORM

Print the form, refer to the patches page for patch name(s), fill it out and mail/fax it in ... 
no information is sent over the internet.
Make checks payable to: Patch Pals

Mail to: 
Patch Pals
PO Box 26
Hiawatha, IA 52233

or FAX with Credit Card Info to 
319-393-2620

Each patch is $10.00 except for the plain patches which are $7.00 each.

Home | Patches

Name:
Address:
City, State, ZIP:
Phone (if we have any questions):
Circle Credit Card Type: 

VISA

MC
Credit Card # Exp. Date
Signature:
Patch Name Left/Right Quantity Amount
       
       
       
       
       
  Description    
OTHER ITEM:      
OTHER ITEM:      
TOTAL  
Sales Tax 5% (Iowa Residents Only)  
Shipping & Handling*  
GRAND TOTAL  

*$3.00 shipping & handling  per order in USA
*$5.00 shipping & handling per order out of country