Order_Form

(X) $1.75		(Y) $2.50		(Z) $3.00
EMBLEM #	QTY.	EMBLEM #	QTY.	EMBLEM #	QTY.
1.		1.		1.
2.		2.		2.
3.		3.		3.
4.		4.		4.
5.		5.		5.
6.		6.		6.
7.		7.		7.
8.		8.		8.
9.		9.		9.
10.		10.		10.
11.		11.		11.
12.		12.		12.
13.		13.		13.
14.		14.		14.
15.		15.		15.
16.		16.		16.
17.		17.		17.
18.		18.		18.
19.		19.		19.
20.		20.		20.
21.		Overstock Patches $.60		Please tell us how you found our site:
22.		1.
23.		2.
24.		3.
25.		4.
26.		5.
27.		6.		Please select a few alternate choices of the same value in the event we may temporarily be out of stock.
28.		7.
29.		8.
For each $30 order, you will receive an emblem of your choice. Please indicate emblem number(s) below.		9.
		10.
		Mail this order form to: Patch Place P.O. Box 6131 Harrisburg, PA 17112		alt. 1.
				alt. 2.
				alt. 3.
free 1.				alt. 4.
free 2.				alt. 5.

EMBLEMS · (X) $1.75 per emblem · (Y) $2.50 per emblem · (Z) $3.00 per emblem Overstock (os) $.60 per emblem			Payment can be made by check, money order, Master or Visa. (All orders must be paid for in U. S. funds) Sorry NO C.O.D.’s __Visa __Mastercard EXPIRATION DATE_____________ 13 or 16 No.’s _______________________________________ Signature:______________________________ (Required on Credit Card Order.) Phone:__________________________________ (In case we have a problem with your order) Name:__________________________________ Street:__________________________________ City:________________________ State:_______ Zip:_________________
ITEM	TOTAL #	TOTAL COST
(X)Emblems		$
(Y)Emblems
(Z)Emblems
Overstock (os)
SUBTOTAL		$
Pennsylvania residents, please add applicable county sales tax		$
Postage and Handling Please refer to chart below
TOTAL		$

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