Phone/FAX
503.831.4703
Web site Address
The A-List
Please put me on the A-List!
Billing
Address
Name:
______________________________________________ Phone: _____-___________
Address:
State:
____ Zip Code: _________ E-mail: _______________________________________
Shipping
Address (if
different from above)
Name:
______________________________________________ Phone: _____-___________
Address:
State: ____ Zip Code: _________
Signature ______________________________________________________________
By signing this form, I certify that I am 21 years or older.
We
currently ship to the following states: Alaska, California, Florida, Idaho,
Louisiana, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Mexico,
North Dakota, Ohio, Oregon, Virginia, Washington, Washington D.C., West
Virginia, and Wyoming.
We will contact you soon to confirm your information and collect credit card details. All information collected will be kept confidential and will be used only for the Amalie Robert Estate A-List.
Please return your completed form by Mail or Fax to:
Amalie Robert Estate
P.O. Box 395
Dallas, Oregon 97338
Fax (503) 831-4703