Upland Order Form

Upland
Order Form
(Print this form
for mailing or faxing.)

Make money orders and checks payable to:
Upland
778 Western Larch Rd.
Newport, WA 99156-8712
1-888-718-0869
(FAX)1-509-447-4470
info@uplandusa.com

Ordered By:

Name:________________________________

Street:________________________________

City:____________________ State:________

Zip:_____________ Phone:_______________

Ship To: (if different than "Ordered By")

Name:________________________________

Street:________________________________

City:____________________ State:________

Zip:_____________ Phone:_______________

Description	Cat #	Color	Qty	Price Each	Total Price
1_______________________	________	_______	______	_____________	____________
2_______________________	________	_______	______	_____________	____________
3_______________________	________	_______	______	_____________	____________
4_______________________	________	_______	______	_____________	____________
5_______________________	________	_______	______	_____________	____________
6_______________________	________	_______	______	_____________	____________
7_______________________	________	_______	______	_____________	____________
8_______________________	________	_______	______	_____________	____________
Card #:___________________________________				Subtotal	____________
Exp. Date: _______/_______				Shipping and Handling	____________
Signature:_________________________________				Tax 7.6% WA resident only	____________
(Check one) MasterCard______ VISA______ Check or Money Order______				Total	____________

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Upland Order Form (Print this form for mailing or faxing.)

Upland
Order Form
(Print this form
for mailing or faxing.)