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PILLERS STUDIO CLAY
3500 Battlefield Blvd. S.
Chesapeake, VA 23322-2422
757/421-2729


internet order form

We appreciate your interest, questions, and comments, so please use this form to share information, to add your name to our mailing list, or to request a printed catalog, even if you do not wish to place an order now.

FIRST NAME:  

LAST NAME:

ADDRESS:

CITY:  STATE:   ZIP:

TELEPHONE:

E-MAIL ADDRESS:

SHIP TO (IF DIFFERENT FROM ABOVE):

FIRST NAME:

LAST NAME:

ADDRESS:

CITY:  STATE:   ZIP:

TELEPHONE:

E-MAIL ADDRESS:

PLEASE SEND ME THE FOLLOWING:
(PLEASE ENTER QUANTITY, ITEM, COLOR, AND PRICE:)
(Please check our
availability chart to be sure the color you want is available on the item you desire)

COMMENTS:

Check here to receive a printed catalog.

Check here to add your name to our mailing list, and we will send you a postcard when we visit your area. Rest assured we will not share this confidential information with any other mailing lists.

Enter the major metropolitan area(s) nearest you:

IF YOU WOULD LIKE TO PAY BY CREDIT CARD,
YOU CAN EITHER PHONE US AT 757/421-2729 WITH YOUR CARD NUMBER,
OR PRINT THIS FORM ON YOUR PRINTER,
ADD YOUR CARD NUMBER AND EXPIRATION DATE,
AND SNAIL-MAIL IT TO US AT OUR ADDRESS ON THE TOP OF THE FORM.

      

THANK YOU FOR YOUR ORDER!


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