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AFTER GETTING A QUOTE, USE THIS FORM

To order through the mail:  PRINT THIS MAIL-ORDER FORM.  Mail to:  Mosquito Lane, 147 Hwy. 11 South, Picayune, MS  39466
*Make checks or MO payable to: Mosquito Lane
*INDICATES REQUIRED FIELD.  IF YOU ARE PRINTING THIS FORM, THIS MEANS THAT YOU ARE PAYING BY PERSONAL CHECK OR MONEY ORDER OR CASHIER'S CHECK THROUGH THE REGULAR MAIL.
MUST BE U.S. FUNDS DRAWN ON U.S. BANK
CREDIT CARDS ARE ACCEPTED BY PHONE OR PAYPAL ONLY!

*NAME:__________________________________________________________________________

*ADDRESS:______________________________________________________________________

*CITY:___________________________________*STATE:_________________________________

*COUNTRY:__________________________ *PROVINCE:_________________________________

*EMAIL ADDRESS:________________________________________________________________

PHONE NUMBER:_________________________________________________________________

ITEM# ITEM DESCRIPTION (OPTIONAL) SIZE Quantity PRICE TOTAL
           
           
           
           
           
           
  SUBTOTAL   $
MS TAX 7%         +

 Go to http://mosquitolane.com/shipping.htm  to calculate shipping.  ADD SHIPPING:  +                   

Grand TOTAL:  $                    

 

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