ConfederateShop
www.confederateshop.com
Printable Order Form

Crossroads Country Store
Shenandoah Heritage Market
4309 South Valley Pike (US Rt. 11)
Harrisonburg, VA 22801

Please Print This Form.   Orders May Be Mailed, Faxed, E-mailed or Phoned-in
Phone (540) 433-2084                  Fax (540) 896-5705                     E-Mail: rexmil5750@aol.com


Name:________________________________________________   E-Mail:_______________________

Address:___________________________   City:_____________________  State:______  Zip:_______

 

Item Description

Item No.

Qnty.

Unit Price

Extended Price
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Total

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Sales Tax . . .

N/A
Shipping- Priority US Mail . . . .
Total This Order . . . .

Method of Payment

Check

  

Money Order

  

MasterCard

  

Visa

  
Name on Card: Card No.
Signature: Expiration Date:

Ordering Instructions

  • Print this Order Form
  • Check off the Method of Payment in the box provided
  • You will be notified by e-mail when you order is received and processed.

 
  • Fill out this Order Form completely, making sure that you enter correct Item No.
  • Phone, Mail or Fax your order

Thank You For Your Order