Name:

________________________________________

 Address:

________________________________________

 City:

________________________________________

 State:

________________________________________ 

Postal Code:

________________________________________

Country:

________________________________________

 Phone: 

________________________________________

Fax Number:

________________________________________

 E-mail:

________________________________________

 Qty:

 Item:

 __________

 Loretta Holloway T-Shirt • 15.00

(  ) M  (  ) L  (  ) XL

Plus $4.00 Shipping
Multiple orders shipped to one address for single shipping charge.
Orders from other countries must be paid in US Currency  only.

Make checks or money order payable to:
Loretta Holloway
P.O. Box 594
Belton, SC 29627-0594