Chillagoe Guesthouse

Order Request for Polo Shirts

Name      

Email      

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Street       (Delivery Address)

Suburb   

Country     Post or Zip Code


Selection 1  Gender & Size Mens - Small Mens - Medium Mens - Large Mens - X Large Mens - 2X Large Ladies - 6 Ladies - 8 Ladies - 10 Ladies - 12 Ladies - 14 Ladies - 16 Ladies - 18 Ladies - 10   Qty 1 Shirt 2 Shirts 3 Shirts 4 Shirts 5 Shirts        Selection 2  Gender & Size Mens - Small Mens - Medium Mens - Large Mens - X Large Mens - 2X Large Ladies - 6 Ladies - 8 Ladies - 10 Ladies - 12 Ladies - 14 Ladies - 16 Ladies - 18 Ladies - 10   Qty 1 Shirt 2 Shirts 3 Shirts 4 Shirts 5 Shirts

Selection 3  Gender & Size Mens - Small Mens - Medium Mens - Large Mens - X Large Mens - 2X Large Ladies - 6 Ladies - 8 Ladies - 10 Ladies - 12 Ladies - 14 Ladies - 16 Ladies - 18 Ladies - 10   Qty 1 Shirt 2 Shirts 3 Shirts 4 Shirts 5 Shirts        Selection 4  Gender & Size Mens - Small Mens - Medium Mens - Large Mens - X Large Mens - 2X Large Ladies - 6 Ladies - 8 Ladies - 10 Ladies - 12 Ladies - 14 Ladies - 16 Ladies - 18 Ladies - 10   Qty 1 Shirt 2 Shirts 3 Shirts 4 Shirts 5 Shirts

Special Comments/Requests

Please supply the shirts as selected above at $38 each including GST plus $10 postage per order within Australia.
For international orders the postal charges will be quoted before order is processed.

Please Charge my Credit Card

Card Type VISA M/CARD     Card Number        Expiry  MM 01 02 03 04 05 06 07 08 09 10 11 12 / YY 11 12 13 14 15 16

Name on Card
            CVV       What is this?