_______Order date & tracking #

___________________________________ _______________________

Customer’s name Telephone number

____________________________________ _______________________

Street address email

____________________ ________ _________ _______________________

City State Zip Cell phone #

□ Prepaid □ cash □ check □ credit card Need by _______________________

□ Payment on delivery/pickup

Qty	Size	Inscription	Price	SPO	Tax	S&H	Total
				$5
				$5
				$5
				$5
				$5
				$5.
				$5
				$5
				$5
				$5
		Total

THE BACKLOG POTTERY 2068 Jacob Tome Hwy Port Deposit, MD 21904

backlog.pottery@gmail.com www.backlogpottery.com 410-658-3959