COLONIAL FURNITURE                  Order Form               Fax to: 06 304 9833

Your Name: ................................................................. Company: ...........................................................

Address: .................................................................................................................................................................

City/Town: ................................................. Telephone: .................................... Fax: .....................................

Email: ................................................................................

Please send me:         
                    Quantity         Item No         Description                      @               Cost

                    ....................................................................................................$...........

                    ....................................................................................................$.........

                     ...................................................................................................$..........               

                    ....................................................................................................$.........

                                                                                                    TOTAL:       $........................

PLEASE CHARGE TO: Credit Card Type:  VISA/MASTERCARD (delete as required)

Credit Card Number: ................................................... Expiry Date (mm/yy): ............../.................

Name on Card: ...............................................................

Signature: ................................................................... Date: .....................................