KeepSafeJewelry Order Form

KeepSafeJewelry a division of	B Independent, Inc. 14720 S. Seminole Dr. Olathe, Ks 66062 FAX: 913-390-7090
Billing Address	Ship to (if different from Bill to)
Name__________________________ Street Address___________________ City____________________________ State______________ Zip _________ Phone ( ) ___________________	Name___________________________ Street Address____________________ City_____________________________ State______________ Zip __________ Phone ( ) ____________________

Payment Method

\|__\|	Check or money order (please enclose)

Charge to:

|__| MasterCard

|__| Visa

|__| American Express

Account #

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiration (mm/yy):

__ __ / __ __

Phone # ( ) ____-____________

E-mail ______________________

____________________________

Signature ____________________

Name (printed) _______________

Merchandise total
8.25% Sales tax (Texas only)
Regular shipping/handling	$9.95
Extra shipping for oversized items
TOTAL
Make check payable to: B Independent