SINCE 1969

Parham's II

 ORDER FORM


16 Fl Oz.

Qty           Price

1          $ 5.00

Case 3     $ 12.00

 6         $ 25.00

 9         $ 40.00

12         $ 55.00

 

18 oz.

Qty          Price

 1        $ 7.00

Case  3   $ 20.00

6         $ 40.00

9         $ 60.00

12        $ 80.00

 

 Gallon  

Qty          Price

1             $ 15.00

3             $ 44.00

6             $ 90.00

9             $135.00

12            $170.00

 

*Shipping Costs May Apply for Larger Orders*

3-5 Day Shipping. All orders under 5 bottles are shipped for free. Any large orders will have a $5.99 shipping charge.

Customer First and Last Name

Customer Address


 

Quantity Ordered

 e-mail address:

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Customers May Pay by Credit Card. Pay Pal, Quick Pay, or Bill Pay

Credit Card Information:

Type or Card ( Example; MasterCard, Visa, or American Express)

My Debit Card Number is                   Expiration Date   

My Credit Card Number is                  Expiration Date       

Three Digit Security Code   ( Located on the back or the front of your credit or debit card)

Name of Financial Institution                                       

Name as it appears on Debit Card or Credit Card     

Address as it appears on  Debit or Credit Card          

Use of Debit or Credit Card:  The debit card or credit card on file will be used as a method of payment.

 I certify that I have read, understand, and agree with the " Use of Debit or Credit Card" statement.

  I certify that I am the authorized user of this debit or credit card. I also agree that I will be responsible for any unauthorized use and held responsible for any balances due after registration.

This is a secure site.  However, if you do not feel secure providing this information on line, please call us @ (708)720-4547 0r 219-629-4168.

 

email mmurphy@accountax.us or text number 708-720-4547 or 219-629-4168

  



Copyright 2017 Parham's II
Revised: 09/12/17.