PGF Shoe Covers - Order By Check

Please fill out the form and print it and mail your check as indicated below:

First Name:
Last Name:
Company:
Street Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming "Click" Arrow for Choices
Zip Code or Postal Code:
E-Mail Address:
Contact Phone:	( ) Ext. (Area Code)(Phone Number)(Extension) (Numbers Only)
	Cases $29.95 ea  300ct/case   QTY 0 1 2 3 4 5 6 7 8 9 10
	Packets $19.95 ea 100ct/packet    QTY 0 1 2 3 4 5 6 7 8 9 10
	Tax (add 7% for Indiana Orders)
	Shipping
	Total Costs