ÿþ<HTML><HEAD> <META http-equiv=Content-Type content="text/html; charset=windows-1252"> <META content="MSHTML 5.50.4207.2601" name=GENERATOR></HEAD> <BODY bgcolor="#FFFFFF"> <div align="center"><font size="3" face="Verdana, Arial, Helvetica, sans-serif"> <strong>Merchandise Order Form </strong></font> </div> <P align="center"><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><em>http://www.daffneyshouse.com</em></font> <P>&nbsp; <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Print this form, fill it out and include it with your order. </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">If you don't have a printer, hand write all necessary info on a sheet of paper and print clearly. </font> <P>&nbsp; <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">NAME:____________________________ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">ADDRESS:_________________________ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">CITY: ___________________________ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">STATE: __________________________ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">ZIP, POSTAL CODE: _______________ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">COUNTRY:_______________________ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">E-MAIL ADDRESS: _____________________ </font> <P>&nbsp; <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>Just check the ones you want!</strong></font> <P><strong><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><em>8 X 10 Pictures</em></font></strong> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">1) ___ Nurse Daffney: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">1) ___ Daffney in zombie dress: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">1) ___ Daffney on travel case: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">1) ___ Daffney/Thumbtacks: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">2) ___ Pulling Ring: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">3) ___ Chainmail / Back: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">4) ___ Daffney/Stevie- watch: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">6) ___ Queen of Hearts: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">7) ___ Daffney as x-23: $5.00 = Quantity: ___ </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">8) ___ Holding Hair Headshot: $5.00 = Quantity:___</font> <P>&nbsp; <P><strong><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><em>T-Shirts</em></font></strong> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif"> Glow in the Dark Scream Team shirt: SIZE ____ (M, L, XL) $19.99 = Quantity:___<br> <P>&nbsp; <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>PERSONALIZED MESSAGE FOR YOUR AUTOGRAPH:</strong></font> <P>&nbsp; <P>&nbsp; <P>&nbsp; <P>&nbsp; <P>&nbsp; <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><B>SHIPPING AND HANDLING: </B> </font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pictures: $2 (Add $1 for additional pictures)</font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Shirts: $7 (Add $2 for an additional shirt. Add $1 if also purchasing a picture)</font> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">International : Add an additional $5 to standard shipping price.</font> <P>&nbsp; <p><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><b>TOTAL :<font color="#FFFFFF"> __ </font>$ ________</b></font></p> <p><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><b>SHIPPING: $ ________</b></font></p> <P><b><font size="2" face="Verdana, Arial, Helvetica, sans-serif">GRAND TOTAL ENCLOSED: $____________ </font></b> <P>&nbsp; <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">MAIL ORDERS TO:</font> <B> <P> <CENTER> <p>Daffney<br> 235 W. Brandon Blvd #230<br> Brandon, FL 33511<font size="3" face="Verdana, Arial, Helvetica, sans-serif"><br> </font></p> </CENTER> </B> <P><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Payment in full must accompany order. No C.O.D'S, No personal checks. All orders must be in the form of Money Order. Cash is sent at your own risk. Allow 4-6 weeks for delivery.</font> </BODY></HTML>