Print out this form then close the window.

Bella Lumina
3234 Kirk Road, San Jose, CA 95124

BILL TO:
Name______________________________________
Address____________________________________
____________________________________________  
Phone (Day)_________________________________
Phone (Eve)_________________________________
E-mail______________________________________

SHIP TO:
Name______________________________________
Address____________________________________
____________________________________________
Phone (Day)_________________________________
Phone (Eve)_________________________________
E-mail______________________________________
Code Item description Quant. Unit Price Amount
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
_______ ____________________________ _______ __________ __________
Subtotal ___________
Shipping ___________
CA residents
add 8.25% tax 		___________
Total ___________
Method of Payment (Circle one)

Money Order        Check        COD        Mastercard        Visa

Please make checks payable to: Bella Lumina

___________________________________
Credit Card Number
_____________________________________
Authorized Signature
_____________________________________
Expiration Date

Shipping:
Items are shipped UPS Ground or US Postal Service.
Shipping is $5.00 plus $2.00 handling per plate. Allow 2 to 3 weeks for delivery.

For questions please call Toll-Free  (866) 866-3044
 

Send order form along with payment to:
Bella Lumina
3904 Bismarck Drive
San Jose, CA 95130