Order Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=90 BGCOLOR="#0000FF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Lucida Bright" ><B>Texas Backroads Furniture</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="Texas Backroads Furniture"><U><B>H</B></U></A><A HREF="index.htm" TARGET="_top" TITLE="Texas Backroads Furniture"><U><B>ome</B></U></A></div> <DIV ALIGN="LEFT"></DIV> <div> <A HREF="id34.htm" TARGET="_top" TITLE="Accessories Frames"><U>Accessories & Frames</U></A>   |   <A HREF="id35.htm" TARGET="_top" TITLE="Antiques"><U>Antiques</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="Bed frames"><U>Bed frames</U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="Benches"><U>Benches</U></A>   |   <A HREF="id23.htm" TARGET="_top" TITLE="Cabinets Entertainment Centers"><U>Cabinets & Entertainment Centers</U></A>   |   <A HREF="id24.htm" TARGET="_top" 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valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000" background="1d864643.gif"> <div> <I>Order Form</I></div> <div> Texas Backroads Furniture</div> <div> <B>7006 Clear Valley Drive, San Antonio, TX 78242      Telephone:  (210) 670-0891</B></div> <div> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="664" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#FFFFFF > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="396"><div> <B>Name: </B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="96"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="96" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="396"><div> <B>Address:</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="96"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="96" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="396"><div> <B>City:</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="96"><div> <B>State:</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="146"><div> <B>Zip:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="396"><div> <B>Telephone - Day:</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="96"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="96" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="396"><div> <B>Telephone - Evening:</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="96"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="96" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="396"><div> <B>E-Mail Address:</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="96"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="96" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="665" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#FFFFFF > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="41"><div> <B>Qty</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF><NOBR><div> <B>Item Name / Description / Type / Color</B></div> </NOBR></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><div> <B>Size</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><div> <B>Price</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><div> <B>Total</B></div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 23 WIDTH="41"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="41" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="371"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="371" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> Shipping charges will be calculated and we will call or e-mail you with a total price.  You may then send us a check</div> <div> or money order for payment, or we will charge the credit card listed below when we ship your order.</div> <div> <B>METHOD OF PAYMENT:</B></div> <div> <B> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="617" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#FFFFFF > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="146"><div> <B>______ Visa</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF><NOBR><div> <B>______ MasterCard</B></div> </NOBR></tD> <tD VALIGN=TOP COLSPAN=2 BGCOLOR=#FFFFFF WIDTH="295"><div> <B>______ American Express</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 BGCOLOR=#FFFFFF HEIGHT= 20 ><NOBR><div> <B>______ O</B><B>ther______________________</B></div> </NOBR></tD> <tD VALIGN=TOP COLSPAN=2 BGCOLOR=#FFFFFF><NOBR><div> <B>______ Check or Money Order</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=4 BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="593"><div> <B>Card Number: </B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=4 BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="593"><div> <B>Expiration Date:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=4 BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="593"><div> <B>Name on Card:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=4 BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="593"><div> <B>Signature:</B></div> </tD> </tR> </TABLE></B></div> <bR> </td> </tr></table></body>