UPHOLSTERIES BY DIXIE INC. DATE: _____________________

92 HARBER AVENUE MAKE OF CAR: _____________

KITCHENER, ONTARIO BODY STYLE: ______________

N2C 1Z2 MODEL: ___________________

YEAR: ____________________

PHONE / FAX 1-519-748-1648

NAME: _______________________________________ SHIPPING: [ ] C.O.D.

ADDRESS: ___________________________________ [ ] PARCEL POST

______________________________________________ [ ] COURIER

POSTAL CODE: _______________________________ [ ] OTHER

PHONE NUMBER: _____________________________

CREDIT CARD #: ______________________________

EXPIRY DATE: __ /__ VERIFICATION CODE_____ CATALOGUE # 2015/16