Date of Order:________________
Name: _______________________________ Contact Person: _____________________________________
Street Address: ________________________________________________________________________________
City/State/Zip Code: _____________________________________________________________________________
Phone Number: Work:___________________________ Home: ________________________
Fax: ___________________________
Ship To (complete only if different from above):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Items Ordered: ___________________________________________ Cost:_________________
___________________________________________ Cost:_________________
___________________________________________ Cost:_________________
___________________________________________ Cost:_________________
6% MI Sales Tax:_________________
Total:_________________
Method of Payment: Cash ______ Check #_________ Charge_________
Cardholder Name: ______________________________________________
Credit Card #:_________________________________________________
Expiration Date: ___________________________
Mail to:
Design Alternatives Home Planners
206 N. Main St.
Suite 2
Davison, MI 48423
