Order Form

All orders must be made payable to: Chuck Mier

not to Altered States Models.

Please print this form, fill out the following information and send to:

Chuck Mier
7732 Yount Rd
Knoxville, TN 37931

Ship To:

Name_____________________________________________________________

Address___________________________________________________________

___________________________________________________________

City_________________________________State________Zip______________

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Quantity _______ Item __________________________ Price Each ____ Total ______

Merchandise Total __________________________            Minimum order of $25.00

8.25% Sales Tax TN Residence only ___________

S&H (See Chart Below)    _____________________

Total Enclosed _____________________________

Shipping Chart:

Total Price of Items:        Shipping & Handling:

$10.00 to $30.00------------$3.50

$30.01 to $40.00------------$4.00

$50.01 and up---------------$5.00

All Overseas orders add $6.00