RashCream.Com - Printable Order Form
You may use this form to mail or fax for your order.
Phone: (815) 965-2981 or
  (815) 332-9405
Fax: (815) 332-3366
Mailing address:
Pal Midwest
P.O. Box 624
Rockford, IL. 61105
Note: you can type in your information right on-line print it out on your printer and just fax or mail it over, or print it out blank and fill it in using a black pen and then fax or mail it over.
Name:
Email:
Address:
City:
 State:  Zip:
Phone #:
Fax #:
 
Credit Card #
Exp. Date:
Name on card:
Type of card:
Paying Via Check or Money order? Please Check Here
 
Paladin Diaper Rash Ointment Quantity: Sub Total:
Palomar "E" Skin Rash Ointment Quantity: Sub Total:
 
Shipping and Handling (See Chart)
Illinois Residents Total (7.25% Sales Tax - See Chart)
 
Total:   
 
Type Comments or a different ship to address into the text box bellow:

If you are paying by check or money order please remember to attach it to this order form.

If you are paying by credit card - Please print account information clearly.


 

Quantity
(2 Oz. Jars)

Price
per Jar

Extended Price

Shipping/Handling

Total

Illinois Residents
Total
(8.25% Sales Tax)
1 $5.45 $5.45 $2.95 $8.40 $8.85

2

$5.45

$10.90

$2.95

$13.85

$14.75

3

$5.45

$16.35

$3.45

$19.80

$21.15

4

$5.25

 $21.00 $5.95 $26.95 $28.68

5

$5.25

 $26.25 $6.45 $32.70 $34.87

6

$5.00

 $30.00 $6.95 $36.95 $39.43

8

$4.75

 $38.00 $7.95 $45.95 $49.09

12

$4.50

 $54.00 $8.95 $62.95 $67.41

24

$4.25

 $102.00 $12.95 $114.95 $123.37