ENGRAVING INFORMATION (Maximum 40 spaces per line) | |
Line # 1 | Today's Date: |
Line # 2 | - - |
Line # 3 | Date Plaque is Needed By: |
Line # 4 | - - |
PLAQUE INFORMATION AND ORDER SUMMARY | ||||
Item | Price | Ship. & Hand | Sales Tax* | TOTAL |
Copper Eagle in Flight | $ 51.95 | $ 23.00 | ||
* Sales Tax @ 7.75% for California Residents only |
Billing Address | ||||||||||||||
|
|
Shipping Address (if different) | ||||||||
We must have a phone number for the shipping address. | ||||||||
|
|
PAYMENT INFORMATION: | |||
Check Enclosed | Credit Card | PayPal | |
CREDIT CARD INFORMATION:
|
|||
Name on Credit Card: | |||
First Name | Middle Initial | Last Name | |
Please make sure that the Billing Address (above) is where the credit card statement is sent. | |||
| |||
CREDIT CARD NUMBER: | EXPIRATION DATE: | SECURITY CODE: (on back of card) | |
Signature: ________________________________________________________________________________ |