Pictou Order Form

CWPUBLISHING ORDER FORM

Quantity Ordered: (@ $12.95 USD)
NOTE: PayPal Temporarily OOC)

* Items are Required Fields !

First Name	*
Last Name	*
Middle
Address 1	*
Address 2
City	*
State
Zipcode	*
Country	*
Email	*

Shipping Information
Uncheck this box if Shipping and Billing are NOT the same

(If you choose to ship to a different location, Enter the information below)

First Name
Last Name
Middle
Address 1
Address 2
City
State
Zipcode
Country