Agapy LLC
Order Form

Name and Address:

Name:_________________________________ Tel. # (_____)_____________________

Ship to:_________________________________________________________________

_______________________________________________________________________

Email Address:_______________________ Fax # (_____)_________________________

Order:

Quantity
 Item Name and/or Description Price Per Item Total Price
       
       
       
       
       
       
Add Shipping (see below and calculate):  
Sub-Total:  
Illinois Residents Only: Add 6.25% Sales Tax  
Total Amount:  
     
Shipping Charges

Shipping to
Price
U.S.

$5 if total order up is less than $19.99
$9 if total order is between $20 & $44.99
$14 if total order is between $45 & $99.99
$20 if total order is between $100 & $199.99
$27 if total order is over $200
Other Countries
 Please email billing@agapy.com for price quote before sending order form.
 

Remittance

Make check or money order payable to Agapy LLC, and mail it with this order form to:

Agapy LLC
Francisco Jaramillo
1023 Woodberry Ln
Charleston, IL 61920