Middle Creek Theatre CD Order Form

CD Title

Price Each

Quantity

 Extended Price
Middle Creek Band(Original)CD $10.00

________

____________
Elijah Chastain (I'll Meet You There)CD $10.00 ________

____________
Angie Larson (Refuge) CD $10.00 ________

____________
Barbara Walker (Reflections) CD $12.00 ________

____________
DVD of Regular Show  DVD $15.00 ________

____________
Jamie (Gumm) Ogle (Forever is Never Too Long) CD $12.00 ________

____________
Angie Larson (Heartsongs) CD $10.00 ________

____________
Shipping and Handling (1-2 CD's - $5.00; - 3+ CD's - $7.50)

____________

GRAND TOTAL

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Name: _____________________________________________________

Address: ___________________________________________________

City: ___________________________ ST ______ Zip Code: ____________-______

Daytime Telephone Number where we may contact you if we have any questions: (________)___________________________________

I wish to pay for my order using (please check one):

 Check Enclosed in the amount of ___________________ (please make check payable to Middle Creek Theatre)
 Money Order Enclosed in the amount of ___________________ (please make money order payable to Middle Creek Theatre)
 I wish to use my credit card.  Credit card information follows

Name as it appears of credit card: ____________________________________

Billing Address: ___________________________________

City: ______________________________ ST ____________ Zip Code _________________

Credit Card Number (We accept Visa, MasterCard) ________________________________________

Expiration Date ____________    Code: ____

I agree to pay the charge of $______________ to my credit card company.

_____________________________________________
Signature