Lampwork Bead Order Form

Name Address City State Zip Code Phone [Format xxx-xxx-xxxx] Fax [Format xxx-xxx-xxxx] Email Striper Beads   Base Color Stripe Color - Input Quantity Price A1 Gold C1 Gold   C2 Pink C3 Blue C4 Seafoam C5 Copper $5.00 A2 Silver C1 Gold   C2 Pink C3 Blue C4 Seafoam C5 Copper $5.00 A3 Pink C1 Gold   C2 Pink C3 Blue C4 Seafoam C5 Copper $5.00 A4 Blue C1 Gold   C2 Pink C3 Blue C4 Seafoam C5 Copper $5.00 A5 Copper C1 Gold   C2 Pink C3 Blue C4 Seafoam C5 Copper $5.00 A6 Seafoam C1 Gold   C2 Pink C3 Blue C4 Seafoam C5 Copper $5.00   Payment can be made by Paypal, details will be provided at the time of order.