Hippie Sticks Printable Fax or Mail Order Form

Hippie Sticks Australia            Ph. Within Aus: 02 4474 2011 - Fax: 02 4474 2569
P.O Box 358 Moruya                 International:(+612)4474 3336 - (+612)4474 0739
2537 NSW Australia                       


SOLD TO:                                 SHIP TO: (If not the same)

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Name                                     Name

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Address                                  Address

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City, State, Postcode                    City, State, Postcode

___________________________________      Delivery: UPS ( ) Australia Post ( )
Phone Number


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| Item                                         | QTY |   Each   |  Total   |
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                                                      SUB TOTAL |          |
                                                                |----------|
                                    For AUS orders, add 10% GST |          |
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                                            Shipping & Handling |          |
                                                                |----------|
PAYMENT METHOD:                                           Total |          |
                                                                ------------
( ) Cheque Enclosed, Make cheque payable to Hippie Sticks.

( )Bankcard ( )Mastercard ( )Visa ( )American Express

Card Holders Name: _________________________

Card Number: ____________________________  Expiration Date: ____________


Signature: ______________________________________________________________