SISAL RUGS ORDER FORM

DIRECTIONS: Print, fill out and fax or mail form.

Or copy, paste, fill out and email as text or Word file.

(Or call in or visit our store!)

NOTE: This is NOT an online order form.

HEMPHILLS RUGS & CARPETS

230 East 17th Street, Costa Mesa - CA, 92627

Name ______________________________________________________________

Shipping ______________________________________________________________

Address

______________________________________________________________

Phone _____________________________Fax:_____________________________

Sisal Material (e.g., SB300)_________________ Rug Size (e.g., 4 x 6)________________

(Select materials and borders at Sisal Rugs page)

□ Tapestry Border Tapestry Material (e.g., TP100) ___________________

□ Cotton/Jute Border

Cotton/Jute Material (e.g, CO700)

□ Single Border: □ Medium or □ Wide 1) ___________

□ Double Border: □ Medium or □ Wide *1) ___________ 2_____________

(*cotton only for double borders) (inside border) (outside border)

Option for Single Border Orders: □ Square Corners □ Mitered Corners (add $60)

Total Price: ___________________ (For pricing, see Sisal Rugs Size & Pricing Grid)

PAY BY: □ Check (enclosed) □ Visa □ MasterCard □ Discover

Card No: ___________________________________________ Exp. _______________

Name as Appears on Card____________________________________________________

Billing Address (if different from shipping): ________________________________________

_________________________________________________________________________