Ascanty Lingerie,              
& Stockings Only
ORDER FORM
Page Lingerie & Accessories

5186 Country Ridge Drive
Rocky Mount, NC 27803


Fill out and Print-out for Mailing, (Post Office)

Name:   
Credit Card Billing Address:
City:    
State:  
Zip:    
Phone:  
E-Mail:  (Required)
THE EXACT NAME & BILLING ADDRESS OF THE CREDIT CARD YOU ARE USING IS REQUIRED

How will you be paying?
Card Number:Expire Date:
Where Will Your Order Be Shipped To? United States Canada  All Other Countries 
Additional Comments or Information:


Style # & Name: Size:Color: 
Quantity: Price:Total: 
Style # & Name: Size: Color: 

Quantity: Price:Total: 
Style # & Name: Size:Color: 
Quantity: Price:Total: 
Style # & Name: Size: Color: 
Quantity: Price:Total: 
Style # & Name: Size: Color: 

Quantity: Price:Total: 
Style # & Name: Size: Color: 

Quantity: Price:Total: 
Total Items Ordered:            

Total Cost:                     

Calif. Sales Tax .0775%         

Shipping Charge:                

Total:                          

Print this Form Out  &  Print for Mail (Post Office)
.
Mail to and make Money Orders to: 
Page Lingerie & Accessories

5186 Country Ridge Drive
Rocky Mount, NC 27803



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[Ascanty Lingerie]    [Stockings Only]