Childrens and baby clothes and personalized gifts from My Miracle Baby Order Form
My Miracle, Inc.
35 Spectacle Lake Drive
Nesconset, NY 11767
Bill To: Ship To:
Name on Credit Card: Name:
Address of Card Holder: Address:
City, ST, Zip: City, ST, Zip:
Email: Phone:
Due to the high incidence of returned checks, this form of payment is no longer accepted.
Credit Card Number:  MC, VISA, AMEX, DISC (circle one)
Expiration Date: CVV Code:

Items Ordered:

Item # Description Price Total
Special Instructions: Subtotal