"Old Fashioned Service With A Smile!!!"
Name (Please print):________________________________________________________
Billing Address:___________________________________________________________
City:______________________________State:_________ Zip:___________ - ________
E-Mail Address: __________________________________________________________
Day Phone:______________________ Eve Phone: ______________________________
Qty 
Description Item/Order Number Sub-Total Item Total
( US Funds Only - No C.O.D.'s )
Card # ______________________________________
Expires: _____/_____ CVV2 Code:______________
Month / Year Last 3 on back of card
Name On Card: _______________________________
Exactly as it appears on your card
SHIP TO ADDRESS: (IF DIFFERENT THAN YOUR BILLING ADDRESS)
Name (Please print):____________________________________________________
Billing Address:______________________________________________________
City:__________________________ State:_______ Zip:__________ - __________
E-Mail Address: ______________________________________________________
Day Phone:_________________________ Eve Phone:_______________________
Signature: ___________________________________
© A Top Doll © A Touch Of The Past 2000-2010. All Rights Reserved.
Qty Description Item/Order Number Sub-Total Item Total
PA Residents Add
6% Sales Tax
NY Residents Add
8% Sales Tax
( US Funds Only - No C.O.D.'s )
Card # ______________________________________
Expires: _____/_____ CVV2 Code:______________
Month / Year Last 3 on back of card
Name On Card: _______________________________
Exactly as it appears on your card
Make Checks / Money Orders To:
A TOUCH OF THE PAST
17517 BERWICK TURNPIKE
GILLETT, PA. 16925 - 9658
OR You Can E-Mail to:
Signature: ___________________________________
© A Top Doll © A Touch Of The Past 2000-2012. All Rights Reserved.
PA Residents Add
6% Sales Tax
NY Residents Add
8% Sales Tax
Make Checks / Money Orders To:
A TOUCH OF THE PAST
17517 BERWICK TURNPIKE
GILLETT, PA. 16925 - 9658
OR You Can E-Mail to:
