Your FIRST Name:    M.I.   LAST Name: 

Your E-mail address (ex: yourname@aol.com): .

Company Name (optional): 

Telephone Number (with area code):   

Cellular or Secondary Telephone Number (with area code):   

Address (NO P.O. Boxes): 

City/Town:    State:    Zip Code: 

Country: 

First Item Inventory No.:    Price: 

Brief Description: 

Second Item Inventory No.:    Price: 

Brief Description: 

Third Item Inventory No.:    Price: 

Brief Description: 

Fourth Item Inventory No.:    Price: 

Brief Description: 

Fifth Item Inventory No.:    Price: 

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Comments or Questions?

Shipping Fees (Jewelry is free in the US.  Contact us for other items): 

ILLINOIS Residents add 7.1% sales tax: 

I want to pay by USPS Money Order.  Please let me know what the total is so I can forward the money order out to Riverbend Treasures within 5 days.

Please send me an invoice from Pay Pal and I will send payment immediately. We will only ship to CONFIRMED addresses.  NO exceptions.

Sorry, No credit cards are accepted at this time. However, you may use them through Pay Pal.

All Fields are REQUIRED (unless otherwise indicated).

Telephone numbers are equally important to verify information and confirm shipment.  Although we try to update items as soon as they sell, it is possible that an item is no longer for sale. 

You can also FAX this to us ANY TIME at 618-251-6289

To send your order, click on "ORDER".  To cancel the order or clear the form, click "CLEAR".