ATIRA  "A Treasure Is Remembered Always"

Order Form

SOLD TO:

SHIP TO:

In Case We Need To Contact You

Price

Color, Emblem, Etc.

Item Description

Qty.

Name_________________________

Address_______________________

Address_______________________

City___________________________

State &Zip _____________________

Name_________________________

Address_______________________

Address_______________________

City___________________________

State &Zip _____________________

Check Box if

Same as Sold To

Phone ________________________

E-Mail ________________________

Additional Information

Subtotal

6% KY Sales Tax if Applicable

Total Amount Due

Check or Money Order Payable To:

ATIRA

P.O. Box 441

Henderson, KY  42419-0441

Thank You !

We Appreciate Your Order

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