Date ___________
Order#___________
BC PATCH, LLC
PMB 501
2063 Main Street
Oakley, CA 94561
Phone: 877-728-2401 Fax: 925-625-7858
Home Page : http://www.bcpatch.com
Email : bcpatch@bcpatch.com
Name _______________________________________________
Address________________________________________________
City/State/Zip_________________________________________
Phone ________________________________________________
Email ________________________________________________
Catalog #....Quantity............Description..........................................Price Each..........Total Price ___________________________________________________________________________ |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________| |________|____________|______________________________|___________|____________|
Subtotal 1_______________________________________________________|____________|
Credit (If Applicable)_________________________________________Credit:|____________|
_______________________________________________________Subtotal 2|____________|
California Residents add 8.25% Tax________________________________Tax:|____________|
Add .50 for 1st patch and .25 for each additional__________________ Shipping:|____________|
Overseas S&H is per current international rates from the U.S.________Subtotal 3|____________|
Credit Card Orders MC___ VISA___ Amt Received:|____________|
Account Number _________________________________________
Expiration Date ________________________
___________________________________________TOTAL AMOUNT DUE:|____________|