Southern Development Corporation
104 Main St. #B, Pine Bluff, AR 71601
Voice or Fax: 870-534-6020

Order Form

Shipping Address

Name _________________________________

Street Address __________________________

City _________________ State ___ Zip ______

Use this part only if paying by credit card

Card type [ ]Visa [ ]Mastercard

Name ________________________________
Print name exactly as it appears on the card
Card Number

Expiration ___ / ___
Month and Year

Date __/__/__ Amount $____

Signature

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Authorization code

Please enter your phone number in case we need to contact you about your order _____________