JOPPA GLASSWORKS, INC.
P. O. BOX 202
WARNER, NEW HAMPSHIRE 03278
(603) 456-3569, Fax at (603) 456-2138

ORDER FORM

PLEASE PRINT THIS FORM ON YOUR PRINTER, THEN FILL OUT AND PHONE, FAX, OR "SNAIL MAIL" THIS INFORMATION TO ME

Click for General Order Information

YOUR NAME

YOUR BUSINESS NAME

MAILING ADDRESS (FOR US MAIL)

YOUR STREET ADDRESS (FOR UPS)

CITY, STATE, ZIP

PHONE (BUSINESS & HOME)

MASTER CARD / VISA / or DISCOVER ACCOUNT NUMBER

_ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _ (EXP. DATE) _ _ / _ _

YOUR SIGNATURE (IF USING CHARGE CARD)

X______________________

I wish to order the following:

  1. _____________________________(ITEM) $_______.____
  2. _____________________________(ITEM) $_______.____
  3. _____________________________(ITEM) $_______.____
  4. _____________________________(ITEM) $_______.____
  5. _____________________________TOTAL $_______.____

If you have any questions please call Dudley Giberson or Carolyn Rordam at Joppa Glassworks, Inc. (603-456-3569).

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