Name_________________________________________

Date__________________________________________

Address_________________________________________________________________________________

City_______________________________ State__________ Zip Code____________ Country____________

Area Code and Phone Number (______)______________ E-Mail Address____________________________

	PRODUCT	DESCRIPTION	Total Quantity	Total  U.S. ($)
	Super Stick Lace Front Rolls	3/4"x108" $5.50/ea.
		1"x108" $5.70/ea.
	"Clear Strip"s 3M "Curved" Qty. A___ B___ C___ "Straight" 1" x 3" Qty___	36 strips/bag. $5.00/ea.
	"Tan Cloth" Strips "Curved" Qty. A___ B___ C___ "Straight" 1" x 3" Qty___	36 strips/bag. $5.00 / ea.
	Clear Rolls 3M	1" x 108" $5.00 Ea.
		1/2" x 108" - $4.50 ea.
	Cloth Rolls	1" x 108".. - $5.00 ea.
		1/2" x 108" - $4.50 Ea.
	Liquid Tape	1/2 oz Bottle w/Brush ($7.00)
		1.4 oz. Bottle w/Dauber ($7.00)
	Glue Remover and Refresher	4.0 oz Spray Bottle ($5.00)
		8.0 oz Bottle Drip top ($8.00)
	Lace Bond	2.0 oz Liquid Bond ($60.00)
	Comb Clips	$2.00 / ea.
	Please include $16.40 for UPS-Ground shipping. UPS 2 Day Air and Overnight shipping is additional. Credit cards will be charged when the order is shipped.
			Total

Make checks payable to: "Custom Hair Online "
Please send total payment of charges at time of ordering.

-----------Credit card balance will be charged when the order is shipped.---------------------

Credit Card Payment  -    Visa____  MasterCard____  Amex____  Discover____  Call Me____

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Number______________________________  Expiration _________ Verification Code _______

Signature___________________________________________    Date______________________