KEITH'S BARBER SHOP 121 S. Broadview St.  Ste. # 3 Cape Girardeau, MO.  63703 Phone:  1-573-334-0430 Tue - Fri  8 am - 5 pm          Sat  8 am - 12 pm (CST) Email:  keithsbarbershop@yahoo.com

	BILLING ADDRESS SHIPPING ADDRESS Name: Name: Address: Address: City:                                                           State:                 Zip: Country:  City:                                                          State:            Zip: Country: Phone # (      ) Email: Phone # (      ) Email:

	QTY ITEM  I.D.   PRODUCT DESCRIPTION PRICE EA. TOTAL

	HAIR TYPE   HAIR PART   HAIR WAVE   BASE SIZE   HAIR DENSITY   HAIR COLOR

	QTY ITEM I.D. PRODUCT DESCRIPTION HAIR COLOR # CAP SIZE PRICE EACH TOTAL

	QTY ITEM I.D. PRODUCT DESCRIPTION PRICE EA. TOTAL

	Save An Additional $ 25.00 on Each Additional Men's Hair System Ordered ! MERCHANDISE TOTAL:   Save An Additional $ 15.00 On Each Additional Women's Hair System Ordered ! MO. RESIDENTS ADD 6.975% SALES TAX:     SUB-TOTAL:     SHIPPING / HANDLING:     TOTAL AMOUNT DUE:

	OFFICE USE ONLY Order # :  _________________________ Order Date:  ______________________ Shipping Date:  ___________________ Shipping Method: ________________ Payment in Full is Enclosed:  (Please Check One) ___ Money Order       ____ Check ___ Visa                       ____ American Express ___ MasterCard         ____ Discover Card Number (Give ALL Numbers on your Card)_____________________________ Expiration Date:______________ Signature: ___________________________________

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