GOPShoppe.com LLC • 899H Airport Park Road • Glen Burnie, MD 21061 • Phone (888) 467-9001 • FAX (410) 761-7807
Order Form
 Customer Information
Name:
Address:
City, State, Zip:
Daytime Phone:
Evening Phone:
Email Address:
 Order
Quantity Product Description Size Item Price Total
         
         
         
         
         
         
         
         
         
         
Subtotal  
   
Shipping Charge (see chart)  
Order Total  
 Shipping Charges
  Payment Information
Order Total Shipping Charge
Up to $15.00 $7.00
$15.01 - $30.00 $7.95
$30.01 - $50.00 $9.95
$50.01 - $75.00 $11.95
$75.01 - $100.00 $12.95
$100.01 - $150.00 $13.95
$150.01 - $200.00 $15.95
$200.01 and up $16.95
Credit Card Information: (VISA, Mastercard or American Express)
Credit Card #:
Expiration Date:
Billing Address:
 
  (only if different from Customer Address)
Or Check Payment
___ Check payable to GOPShoppe.com LLC enclosed
 Mail To:
  GOPShoppe.com LLC
Attn: Order Department
899H Airport Park Road
Glen Burnie, MD 21061