Goose Tracks Quilts Secure Order Form

Secure Order Form
This order form is secure. It is encrypted
during transmission using Secure Socket Layer(SSL) technology
so you can safely use your credit card.

BILLING INFORMATION
SHIPPING INFORMATION
Fill in only if different from billing address

Name
Address
City
State Zip Code
Country Name
Address
City
State Zip Code
Country

CONTACT INFORMATION

Phone Number with Area Code Fax Number (if applicable)

E-mail Address

PATTERN
NAME COLOR SAMPLES ONLY
no charge-yes/no HOW
MANY? COST
PER ITEM ITEM
TOTAL COST

Subtotal (no charge for samples)

Shipping & Insurance* - see below (no charge for samples)

NY Residents Add 8% Sales Tax

Total Cost (US Funds Only)

50% Deposit Required

* Shipping:
US 48 States: Please add $10.00.
Anywhere else will be charged at actual cost.

Include any comments or other information here...

PAYMENT INFORMATION

Select Payment Method Cardholder's Name Credit Card Number Expiration

For personal checks and money orders, verify amount and mail to:
Goose Tracks Quilts
354 Bogden Road
Broadalbin, NY 12025
To e-mail me - cathy@goosetracks.com
Before you submit,
please be sure the form information is correct and complete.
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