CHECK AND MAIL TO:
Merri Zielenski
53 Bellhaven Road
Brookhaven, NY 11719
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E-MAIL:
CaneCovers@gmail.com
PHONE:
(631)286-3842

ORDER FORM FOR RUBBER TIP CANE

(IF RUBBER TIP CAN'T BE REMOVED, USE TRI/QUAD ORDER FORM)

Name_____________________________________________________________________________________________

Address_________________________________________City, State, Zip_______________________________________

Email address__________________________________________ Phone_______________________________________


CANE TYPE

Straight   or   Curved   (SELECT ONE)

Length of Cane in inches:                        (from base of handle to end of cane, including rubber tip)

Circumference in inches: just below handle                         

Circumference in inches: at adjustable point                        

(If adjustable part is greater than 3 1/2 inches, use order form for tri/quad cane)

FABRIC PATTERNS                                                                                                                                                                                                

                                                                                                                                                                                                               

AMOUNT DUE:

 

Starter Kit* $14.00 (Includes 1 cover)......................................$                        

Cane Covers ($13 each or 3 for $37)......................................$                        

Postage .......................................................................................$        $4.00       

TOTAL...........................................................................................$                        


*First time order requires one starter kit per cane and includes one cover (don't forget fabric choice for cover).
Additional orders for the same cane do not need starter kits or measurements (I keep measurements on file).