RETAIL ORDER FORM
Date ____________Buyer ____________
P.0.______________________________
Phone ____________________________
SHEEPSKIN RANCH, INC.
3408 Indale Road, Fort Worth, TX 76116
office: (817) 738-2485
Fax: (817) 738-1970

BILL TO:
Name    ________________________________
Address _______________________________
City   _________________________________
State ______ Zip Code: ___________________

SHIP TO:
Name    ________________________________
Address _______________________________
City   _________________________________
State ______ Zip Code: ___________________
ITEM # DESCRIPTION PRICE QTY AMT
101 Medical Sheepskin 105.00 ea    
102 Sheepskin Elbow Protector 30.00 ea    
103 Sheepskin Heel Protector 30.00 ea    
104 Sheepskin Hospital Bed Size (32" x 72") 450.00 ea    
105 Double Medical Sheepskin (Long) 225.00 ea    
110 Wheelchair Seat Cover 120.00 ea    
111 Wheelchair Seat Pad (18" x 16") 60.00 ea    
112 Wheelchair Arm Rest (Regular) 40.00 pr    
113 Wheelchair Arm Rest (Desk) 40.00 pr    
114 Crutches Accessory Kit 35.00 pr    
117 Medical Sheepskin Slippers* 80.00 pr    
118 Medical Sheepskin Slippers* (Open Toe) 80.00 pr    
119 Medical Sheepskin Slippers* (Open Heel) 80.00 pr    
120 Walker Hand Grips 35.00 pr    
121 Forearm Crutches Kit 35.00 pr  
201 Pilates Reformer Strap Cover 48.00 pr    
Sub-Total    
Sales Tax    
Shipping    
Total    

* Please specify sizes of Medical Slippers: S, M, L, XL, (Men's & Women's)   __________________

Method of Payment:
[ ] My check is enclosed
[ ] My check is in the mail*
[ ] Charge my:    [ ] VISA     [ ] Master Card

Credit Card Number:__________________   Expires:_________   Signature:___________________

* No order will be shipped without receipt of payment.

NO RETURNS WITHOUT WRITTEN AUTHORIZATION
WARRANTY: Defective Items Repaired/Replaced at No Cost Within 30 Days