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SAMSON® MONSTER TRUCK MAIL IN
MERCHANDISE ORDER FORM

To Order by Mail, please print this form out and provide the following information:

ITEM SIZE QUANTITY PRICE TOTAL
         
         
         
         
         
         

Shipping & Handling Charges *

$25 or Less ........................ $8.00 
$26 - $50 ............................$10.00
$51 - $75 ............................$12.00
$76 - $100 ..........................$14.00
Ohio Residence add 7% State Sales tax.

Allow 2 - 4 weeks for delivery. Please include a street address for all orders
as UPS does not deliver to P.O. Boxes!

* Alaska, Hawaii and International shipments – extra shipping charges will apply.
Alaska & Hawaii - please add $5.00
International - please add $10.00

Subtotal  
State Sales Tax
Ohio ONLY - 7%
 
Shipping/Handling  
ORDER TOTAL  
   
Name  
Street Address
(No P.O. Boxes Please)
 
City  
State  
Zip Code  
Phone number  

Allow 2 - 4 weeks for delivery

If paying by Check, Money Order or mail in Credit Card information:
please complete order form along with with shipping (and additional Ohio 7%) tax calculations
and mail the completed form to:

Patrick Enterprises, Inc.
8564 Zane Trail Rd.
Circleville, Ohio  43113

Credit Card Info:
Visa, Mastercard, Discover, or American Express


Name on Card: ___________________________________

Billing Address For Card:___________________________

Credit Card Type : _________________


Credit Card Number:________________________

CVC Security Code (3 or 4 digits):
__________


Exp. Date: _________________
(month & year)__________

For Questions Or More Infomation:

Contact Us

Thank-you!

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