DOWN ISLAND INC. Order Form
111 South Front Street * Wilmington, NC 28401
800-700-2112

Please fill in and print the form below then fax it to us at 910-762-0270
All information is confidential and will not be sold or shared for marketing purposes.

First Name: Last Name:

Billing Address:
Address 1: City: State:
Zip or Postal Code: Country: Daytime Phone:

Shipping address if different from above:
Address 2: City: State:
Zip or Postal Code: Country: Daytime Phone:

ITEMS :

Qty: Item #: Item Name: Price:
Qty: Item #: Item Name: Price:
Qty: Item #: Item Name: Price:
Qty: Item #: Item Name: Price:
Qty: Item #: Item Name: Price:
Qty: Item #: Item Name: Price:
Qty: Item #: Item Name: Price:
Shipping and Handling Charges:
Up to $20.00 $5.95 $75.01 - $85.00 $12.95
$20.01 - $30.00 $6.95 $85.01 - $100.00 $13.95
$30.01 - $45.00 $8.95 $100.01 - $200.00 $14.95
$45.01 - $60.00 $9.95 Over $200.00 10%
$60.01 - $75.00 $10.95 Certain oversized,
heavy or odd shape items
if additional charge
is applied customer
will be notified

Subtotal:
7 % NC Sales Tax:
Shipping & Handling:
Total Due:

Method of payment:

Check or money order enclosed made payable to Down Island. Bill my credit card as follows:

Visa Mastercard Discover Card Number Expiration Date

Signature of cardholder


800-700-2112