*If sending multiple orders use seperate form for each order.
(Multiple orders receive an additional 10% off)

 

Name:

________________________________________________________*
 

Address:

________________________________________________________*
 

City:

________________________________________________________*
 

State:

________________________________________________________* 
 

Phone:

________________________________________________________* 
 

Email:

________________________________________________________
 

Type of item being sent:
(shoes, boots, cap, etc.)

________________________________________________________*

    Personalized Inscription
(shoe mounts only)
 

To:

________________________________________________________
 

From:

________________________________________________________

 

Mounting Style #:

_____________ *

Marble Color: 

_____________
 

Finish:

_____________ (for gold, silver, or pewter add $75.00)    
 
Nameplate (Optional. Add $8.00)		    
 

Name:

___________________________

DOB:

______________

 

Payment Method:

Check Money Order Visa Mastercard    
 

Credit Card #:

_____________________________________    
 

Exp. Date:
(mo/yy)

_______________    
         
 

Subtotal

     
    If you are sending multiple orders deduct 10%    
    Missouri Residents add 7.725% Sales Tax    
    Shipping and Insurance (US Residents)$15.00    
 

Total:

______________    

Signature:

_______________________________________
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Copyright© Family Heirlooms
3950 N 20th Street, Ozark, MO 65721
March 2, 2007
Contact: Customer Service
  417-581-1048

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