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| Philly
Tough |
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www.phillytough.com |
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FAX: (888) 351-5008 |
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24-hour fax line |
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| Billing
Address |
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Shipping Address (if different) |
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| Name:
_____________________________ |
Name:
_____________________________ |
| Street:
_____________________________ |
Street:
_____________________________ |
| City:
_______________________________ |
City:
_______________________________ |
| State:
______________________________ |
State:
______________________________ |
| Zip:
________________________________ |
Zip:
________________________________ |
| Email:
______________________________ |
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| Phone:
_____________________________ |
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| Payment
Method |
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Money Order |
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Visa |
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American Express |
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Master Card |
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Discover |
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| Card
#: __________________________________________________________________ |
| Exp.
Date: _______________ |
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Card Verification #:
___________ |
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| QTY |
DESCRIPTION |
PRICE |
SIZE |
TOTAL |
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13.99 |
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SUBTOTAL |
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Verification Number |
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SHIPPING & HANDLING |
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TOTAL due |
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*We currently only stock sizes S, L, XL |
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Visa, MC, Discover |
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(3 digit) |
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Order Amt |
S+H Cost |
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Less than $50 |
$5 |
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$50 to $99.99 |
$10
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$100 to $199.99 |
$15
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American
Express |
$200 + |
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$20
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(4 digit) |
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