ANTHRACITE HERITAGE MUSEUM STORE
ORDER FORM
RR1 BALD MOUNTAIN ROAD ~ SCRANTON, PA 18504

Order by phone: (570) 963-4804

Order by Fax: (570) 963-4194

Ordered By:  Ship To: (If different from Ordered By)

Name___________________________________
Name_____________________________________

Address_________________________________
Address___________________________________

_______________________________________
__________________________________________

City ___________________ State ___ Zip _____
City ______________________ State ___ Zip _____

Please provide a phone number in case we have a question about your order (_____)______________

Gift Message: _________________________________________________________________

DESCRIPTION

QUANTITY

 

PRICE EACH

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  METHOD OF PAYMENT: Please do not send cash.

I’ve enclosed a check or money order, made payable to Anthracite Heritage Museum Store

in the amount of $_____________.

(Returned checks are subject to a service charge for the greater of $15 or the maximum amount allowed by state law.)

 
CREDIT CARD PAYMENT:

Please charge my -     Visa ____            Mastercard ____  

Include complete credit card number:

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 


________________________________________
Card Holder’s Signature  
Required if using Credit Card		 Expiration Date  

 ___ ___  -  ___ ___  
   Month          Year  

SHIPPING AND HANDLING CHARGES ARE ON AN ITEM BY ITEM BASIS

PLEASE CALL THE MUSEUM TO FIND OUT THESE CHARGES
BEFORE MAILING, OR FAXING YOUR ORDER


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