Date:

               Name:                                                                                                                                                          

              Address:                                                                                                                                                      

              City:                                                                State:                          Zip:                                             

               Phone:                                                             E-Mail:                                                                              

Shipping Fees for Bears (including Insurance):

 Up to $100=$12.50    $100 - 250=$15.50    $250 - 500 =$18.50    Over $500 =22.50          

                                                                           Int’l customers add $5.00 to above shipping fees.                                                                       

                                                                           Special Requests/Shipping Instructions:                                                                               

 On separate paper, please specify request or if a gift specify card message and recipient’s shipping address.        

          How did you learn about Collectible Heirloom Teddy Bears?    ____________________________________________                                                                                         

 Credit Card Payment

                          MC/VISA# ____________________________________________ EXP.____/____                                                                                 

Please enclose your check or money order (made payable to: Collectible Heirloom Teddy Bears) and mail to:

Collectible Heirloom Teddy Bears

Sue Fitzpatrick

PO Box 748

Cheshire, MA 01225

Thank you!