Sign up for auto shipment at The Silkworm Shop

Name:
Phone Number:
E-mail:
Product(s) to Autoship:
How Often Would You Like This Product Shipped?
Begin Auto Shipment On:	Month: Day:
Ship Via:

Billing Information
Name:
Street:
City:
State:
Zip:

Shipping Address
Shipping Address is the same as Billing Address
Ship To Name:
Street:
City:
State:
Zip:

Payment Information
Credit Card Check Money Order Purchase Order:
Credit Card Number:
Expiration Date:	Month: Year: CVV2: What's This?

Miscellaneous Instructions/Comments: