Grown-Up Birthday Order Form

Secure On Line Order Form

Credit Card information required for all on line order form submissions.

If you wish to order by check or money order please fill the form out, print and mail to the address below.

When you have completed the entire form please click on the "Submit Order" button at the bottom of the page. If you wish to start over click on the "Clear Form"button.

Please complete a separate form for each order.

AD&J Enterprises
4600 FM 1645
Timpson, Tx 75975
936-254-2677

Birthday Book $ 14.95 plus $5.00 shipping and handling

My Birthday Surprise

Information Required for Birthday Book
First Name
Middle Name (Optional)
Last Name
ManWoman
Grown-Up's Age
Hometown
State

Date of Birth
Friend (co-worker for The Retirement Book)
Friend (co-worker for The Retirement Book)
Dedication (With Love From, etc.)
Who Book is From (Bob and Betty,etc)
Date of Gift (mm/dd/yy) (Optional)

Customer Information
Your Name
Street Address
City
State
Zip

Please provide us with a means to contact you in case we have questions regarding your order:

Phone
E-Mail Address

Ship Book(s) To (If other than address above)
Your Name
Street Address
City
State
Zip

Payment
$14.95 each Book
Sales tax 7.75%(Texas residents Only)
Shipping $5.00
Total Cost

Credit Card Information

Credit Card

Card Number
Expiration Date (mm/yr)
Name Exactly as Printed on Credit Card
Address where you receive your credit card bill
Security Code number from back of card ( What does this mean?)

Thank you for your order!
Please don't forget to submit your order by clicking on the submit button below.

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