The Country Loft
"Across the Wide Missouri" Block-of-the-Month Order Form

___After entering the information below, your credit card will be charged for this month's block and for each of the previous blocks. Then, when we ship each of the remaining blocks, your card will be charged for that block.
___These charges will be handled separately from other purchases you may make which will be paid for when you finish shopping and check out.



__Name:
__E-mail address:
__Address:
____Street:
__
________
____City:
_- Zip: State:
__Phone:_ _
__Credit card type: _Card #:
__Name on card:
__Expiration date: