Order Fax Form-Fax number is 952-253-3891

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www.asimplertime.com
A Simpler Time-Mall of America
284 South Avenue, Bloomington, MN 55425
Phone: (888) 851-9088
Fax: (952) 253-3891

Qty Name of Item Price of Item Personalization

(as seen on website) (as seen on website) (if applicable)

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Bill To: Ship To: If same as bill to: please just write same.

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Customer Info

Contact phone number _____________________

Email Address ___________________________

Credit Card Info

Credit Card Type______ Card #_____________________ Name on Card______________________ Exp:_______

Your Signature:___________________________________________________

Special l Instructions: