Terra Glass Factory Inc. 45 Bridgeway Middlebourne West Virginia 26149
			Order Form
	Name:_______________________________________ Mailing Address:_______________________________ City_________________________State___________Zip______________ Telephone Number:_____________________________________ Email Address:_________________________________________ List Here                                                                              Cost Item Number 1. 2. 3. 4. 5.                                                                                                Total Cost______________                                                                  WV Residents add 6% sales tax______________          (USA Residents/US Military Overseas ONLY)Flat Fee Shipping Charges_____$5.50_______                                                                                                       Total____________________ *Please note: Shipping charges are excused if you are picking up your items at one of our    authorized Retail Locations listed on our website.                                                                 Print this order form, fill out and mail to us at the above listed address                                                                THANK YOU!