The Cuckoo's Nest | Order Form

Order Form

Complete this form, print it and fax it to us at (978) 463-6890. Or print it now and fill it out by hand. Whichever is easiest for you!

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Subtotal:
Shipping:
Sales Tax:	(5% MA Residents Only)
Total Amount:
BILL TO: ( * signifies required fields)
* Name:
* Street Address:
Address (cont.):
* City:
* State/Province:
* Zip/Postal Code:
Country:
* Home Phone:
E-mail:
SHIP TO: (if different from BILL TO address)
Name:
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
Country:

PAYMENT:

You can pay by Credit Card or send your Check/Money Order to:

The Cuckoo's Nest
11 State Street
Newburyport, MA 01950

We accept...

Credit Card Type:
Credit Card #:	DO NOT USE SPACES OR HYPHENS (DASHES)
Expiration Date:	Enter Expiration Date in MM/YY Format
CCD Code:	REQUIRED: 3 Number Code on Signature Panel of Card

Note: If paying by Check/MO, product(s) will be shipped out when payment is received.

YOUR ORDER WILL BE CONFIRMED BY E-MAIL. IF YOU PREFER A TELEPHONE CONFIRMATION, PLEASE REQUEST THIS IN THE COMMENT SECTION.

Comments / Special Instructions: