Bradco/B. Leyman
15430 Tulsa St. #27
Mission Hills, CA 91345
Tel: (818) 898-2069    Fax: (818) 898-2069
Cell: (818) 414-9134
 

NAME:__________________________________________ DATE:___________________

ADDRESS:_______________________________________ PHONE:__________________

CITY:_____________________________________ STATE:_______ ZIP:_____________

Credit Card Purchase (Circle One)        Master Card        Visa        Discover

Card number:_________________________________________ Exp. Date:__________

Cardholders Signature:_____________________________________________________
                                    All terms of my charge account agreement apply to this purchase

Qty.      Description                                      Price              Total   

_____    RED TOP (MIXER PLUS) SALSA MAKER  $19.95 each      $______

_____    RED TOP (MIXER PLUS) SALSA MAKER
            & EDGE 2001 KNIFE                           $24.95 each      $______

_____    Shipping, handling, insurance              $ 8.95 each     $_______
                                        2-4 machines         $ 6.95 each     $_______
                                           In CA, AZ, UT, add sales tax       $_______    
                                                               
                                                               GRAND TOTAL       $_______
 

                                                                                   Please make checks payable to:
                                                                                B. Leyman

Thank you for your order!
www.thesalsamaker.com