Secure Payment Form

Kulie Originals Order Form
You can fill out this form, print it and mail it,
Or you can call and place your order.

Kulie Originals - Rt 1 Box 1610 Cross Timbers, MO 65634 - 417 998 6813

Please enter your details, fields marked with are required!**
Business Name (if applicable):
Contact Person**:
Phone Number:
Fax Number:
E-mail**:double check this entry
Delivery/Mail Address (Address, Zip etc):
Below please enter Cardholder's Address exactly as shown on Credit Card statement!
Cardholder's Name as on card**:
Street Address**:
City+Postcode**
Country**:
State/Province/County:
Zip**: Non-USA use 99999

If You reside In Missouri, State Tax of 7.225 % must be added to the sales amount.
If this applies to you please check the box

Sales Tax 7,225 % will be added to the sales total.

Shipping and Handling	AMOUNT
Shipping and Handling $6.50, basic order. If ordering mugs: for over 2 mugs add $1.00 per mug.