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ORDER FORM

BELL MOUNTAIN MUSIC 

 NAME_______________________________________________

 ADDRESS_______________________________________________   

 CITY______________________________ST______ ZIP______________

 PHONE____________________________e-mail____________________  

ITEM #

DESCRIPTION

#

PRICE
       
       
       
       
       
       
       
       
       
       
       
       
       

 PAYMENT METHOD (CHECK ONE)

 _____ CHECK, MONEY ORDER, CASHIERS     
 _____ VISA
 _____ MASTERCARD
 _____ DISCOVER
_____  AMERICAN EXPRESS

 CARD #__________________________________
 EX DATE ______  3 Digit Security Code_____       ((On back of Card after Credit Card Number)

 SIGNATURE_______________________________
  e-mail:  bellmtnmusic1@windstream.net
 MAIL TO:
 BELL MOUNTAIN MUSIC
 8662 Oakview Road
 Melrose, FL 32666

 PHONE: (352) 475-2134 or (352) 256-8117 (cell)

TOTAL ____________

        FLORIDA RESIDENTS

6% SALES TAX ____________

Shipping & Handling ____________

TOTAL ORDER ____________

Shipping & Handling Charges Add:             

$3.00 up to $29.95                  

$4.00 up to $39.95                  

$5.00 up to $99.95                  

    $6.00 up to $199.95                     

CONTACT US FOR INTERNATIONAL SHIPPING COSTS
CANADIAN ORDERS: POSTAL MONEY ORDER
IN US DOLLARS OR VISA/MASTERCARD/DISCOVER/AMERICAN EXPRESS