Simple Luxuries
Mail to: Box 245  Lantzville, BC  Canada  V0R 2H0
or Phone/Fax to: 1-250-390-1987 

  Sold To:                                                                                                                                          Ship To:      

___________________________________
Name
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Address
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City                     Prov/State        Postal Code
______________________________
Phone                         Fax
______________________________
 Email Address           		 ___________________________________
Name
___________________________________
Address
___________________________________
City                     Prov/State        Postal Code
________________________________
Phone                         Fax
______________________________
 Email Address
Special Instructions:_______________________________________________________________

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Payment Method:  Cheque (__)   MasterCard (__)   VISA (__)
Cheques payable to Simple Luxuries
Card #_______________________________ Expiry Date:__________________________
ALL PRICES ARE IN CANADIAN FUNDS

Product Qty Price Each Total Price
       
       
       
       
       
       
       
       

Sub-Total 

  

  P.S.T. (BC only)  

 

G.S.T. (Canada only)  

 

 Shipping  

  

                            Total