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Shipping Information (if different than Billing)
Name Name
Address: Address:
City:                                             State:         Zip: City:                                             State:         Zip:
Country: Country:
Daytime Phone: Daytime Phone:
Email: Email:
 
Item Number Qty.

Price

 Sub-Total   Item Number Qty.

Price

 Sub-Total
               
               
               
               
               
               
               
                
               
        Sub-Totals   
        *Shipping   
        TOTAL   

*To expedite the shipment of your order, please call us before mailing in this form for final shipping costs.

Dayna's Market
26300 Ford Road
Suite 407
Dearborn Heights, MI 48127

1-313-999-1980
Email: info@daynasmarket.com



Name on Credit Card:
Billing Address:
 
Visa      MasterCard     
Number:
Expiration Date:                                             CVV No. back of Credit Card (3 digit)
SIGNATURE:
 

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