Name of Item Desired: ______________________________________________

Shipping Costs are $______ + Item cost of $ ________ or a total cost of $___________.

Check or Money Order payable to: Delmatto Glass

Please Type or Print CLEARLY:

Name: ________________________________

Address: ______________________________

City: __________________________________

State: __________ Zip: ___________________

Phone: (_____)_______________

Date: _________________________

Mail to: Del Matto Blown Art Glass

32201 Logan Horns Mills Road

Logan, Ohio 43138

Thank you for your order.