PETER'S ROW ORDER FORM

SHIP TO:

	NAME___________________________________________

	ADDRESS 1______________________________________

	ADDRESS 2______________________________________

	CITY___________________________________________

	STATE___________________ ZIP CODE______________

  QTY  ITEM NAME                         PRICE         TOTAL

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                                             SUBTOTAL___________
SHIPPING INFORMATION
Shipping & Handling: One Item $4.00 -
$1.50 Each additional Item                   S & H  ____________

                                             TOTAL COST_________                       
										

Make check payable to Rachel Walczyk.

Please allow two weeks for delivery!

Mail this form and your check to:

                   Rachel Walczyk
                   Peters Row Publishing
		   9 Doral Lane
		   Yaphank, NY 11980