Date ___________
Order#___________
BC PATCH, LLC
PMB 501
2063 Main Street
Oakley, CA 94561
Home Page : http://www.bcpatch.com
Email : sales@bcpatch.com
Name _______________________________________________
Address________________________________________________
City/State/Zip_________________________________________
Phone ________________________________________________
Email ________________________________________________

Catalog #....Quantity............Description..........................................Price Each..........Total Price
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Subtotal 1_______________________________________________________|____________|
Credit (If Applicable)_________________________________________Credit:|____________|
Discounts for Valued Customers_______________________________Discount:|____________|
_______________________________________________________Subtotal 2|____________|
California Residents add 8.25% Tax________________________________Tax:|____________|
Add 1.00 for 1st patch and .25 for each additional__________________ Shipping:|____________|
Overseas S&H is per current international rates from the U.S.________Subtotal 3|____________|

Credit Card Orders  MC___  VISA___                                          Amt Received:|____________|
Account Number _________________________________________ CVV _______________
Expiration Date ________________________                                                                            
___________________________________________TOTAL AMOUNT DUE:|____________|