Text Box: DAHNCO, INC. 1309 East County Road M, River Falls, WI 54022 715-425-7089 Fax: 715-425-1707 www.countryeclectic.com country@countryeclectic.com
 
  Retail Order Form      
        Spring & Summer 2005      
         
             
         
         
                               
      Customer Billing Address Customer Shipping Address (if different than Billing Address)      
      Name: Name:      
      Address: Address:      
      City: City:      
      State: Zip Code: State:   Zip Code:        
      Phone Number: Phone Number:      
                 
         
      Qty Scent Description Unit Price TOTAL      
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
      Payment Method     SubTotal          
      ___ Check     ___ Money Order     ___ Credit Card   Shipping & Handling          
      Credit Card Information           TOTAL          
      ____ VISA    ____ MasterCard    Exp. Date:___________            
      CVV2 (last 3 numbers on signature line on back of card): ________________          
                       
      Name on card___________________________________________     Shipping & Handling Chart      
       
 
        Order Subtotal S/H Rate      
      Card Number:      Up to $20.00 $4.95      
            $20.01 to $30.00 $5.95      
      Signature_____________________________________________ $30.01 to $40.00 $6.95      
     
Make Check or Money Order (U.S. Funds Only) Payable to DAHNCO, INC..  No COD's or cash please.Please allow 2-4 weeks for delivery.  All returned checks will be subject to a $20.00 charge.
Orders Exceeding $500.00, additional time may be required.
 
    $40.01 to $50.00 $7.95      
        $50.01 to $75.00 $8.95      
        $75.01 & over (excl.S/H): Free Shipping      
         
         
      Handcrafted Soaps, Potpourri's, Toiletries, Candles & More . . .