Ordered By: Name: _________________________ Address: __________________________ City: ________________________ State: _____ Zip: ________ Home Tel: _________________ Work Tel: _________________ Shipped To: Name: _______________________ Address: __________________________ City: ________________________ State: _____ Zip: ________ Quant. Item# Description Color Choice(s) Size Item Price Total Price                                                                                     Remember: S/H fees are: $25.00 and under -- $7.00 $26.00 - $50.00 -- $10.00 $51.00 - $100.00 -- $15.00 $101.00 and over -- $20.00 Add $30.00 for any overseas shipments. Trouble with sizes? Please see our Size Chart. Subtotal   Illinois residents add 10.25% Sales Tax   Shipping and Handling Fees   Deduct Discount, if applicable   Total   To pay via Credit Card, please provide the following: Credit Card purchases must be over $25.00 Type of Card: Visa, MC, AMEX, Discover Card Number: ____________________Exp Date: ___/____ Email Address: _______________ Signature: __________________________ Card Holder's Name:________________________ Madame X Lingerie 3023 N. Clark Street, #271 Chicago, IL 60657-5205 1-773-871-LOVE (5683) You may Fax Credit Card Orders to 1-773-528-0944 mxl@madamexlingerie.com