ROUND BACK DINING GROUP ORDER PAGE

Card Holder,s Name

Name    First    Middle InitialLast

Address          

City                 

State                          Zip

Phone number  

E-Mail Address

Visa       Expiration Date

Master   Expiration Date

Amex     Expiration Date

Discover Expiration Date

*NOTE: You will be notified of the shipping cost when order is submitted. No order will be processed until
shipping cost is approved by the customer.

3184 Round back 5pc. dining group. 42" Round glass top table & 4-Arm Chairs QuantityColor White Only $449.00

COMMENTS & SPECIAL INSTRUCTIONS     

  USE "RETURN TO FORM"   TO CORRECT INFORMATION ON ORDER FORM.