ORDER FORM

QTY  NAME OF ITEM             FINISH              PRICE EACH    TOTAL
===  ============             ======              ==========    =====

___  ________________________ ___________________ ___________ ___________

___  ________________________ ___________________ ___________ ___________

___  ________________________ ___________________ ___________ ___________

___  ________________________ ___________________ ___________ ___________

___  ________________________ ___________________ ___________ ___________

                                                   Sub-Total: ___________

                                                    Discount: ___________
                            (Less discount of 3% for 2 items;
                             6% for 3 items; 10% for 4 items)

                                             Total Purchases: ___________

                  Georgia Residents add applicable sales tax: ___________
					 

                                                       TOTAL: ___________


BILL TO
=======

NAME: ___________________________________________________________

STREET: _________________________________________________________

CITY: _______________________________ STATE: ___ ZIP: ___________

DAYTIME PHONE: (_____)_______________



SHIP TO
=======

NAME: ___________________________________________________________

STREET: _________________________________________________________

CITY: _______________________________ STATE: ___ ZIP: ___________

DAYTIME PHONE: (_____)_______________



METHOD OF PAYMENT
=================

__ Money Order


__ Check Included


__ VISA    __ MasterCard     __ DISCOVER      __ American Express

Card Number: ___________________________________

    Expires: __________

  Signature: ______________________________________



                    The Brumby Chair Company Guarantee

   We stand behind every product we sell. If for any reason whatsoever you
      are not totally satisfied, simply return it to us for replacement,
     or immediate, no questions-asked refund (excluding delivery charges).
           The Brumby Chair Company guarantee is backed by over
                120 years of honest service to customers.