POLY-KOTE PIN ORDER FORM
The following information may be printed to your printer and sent directly to us in the mail along with your art work.
(Fill in the information below and select the "PRINT" button on your browser....
Mail to: S.R.E. Pins • P.O. Box 6369 • Burbank, CA 91510-6369
Name:
Company:
Email:
Phone: FAX:
Address:
City: State: Zip:
Country:
QUANTITY
CODE #
SIZE
EACH
TOTAL
Shipping ViaUPS Gnd UPS 2 day UPS next
(check) I WANT A MILITARY CLUTCH ON MY PINS
QUANTITY
DESCRIPTION
EACH
JEWELERS TIE TAC FIXTURE
.50
SAFETY CLASP FIXTURE
.12
ORDER SUB-TOTAL
8.25% CALIF SALES TAX
FOR DELIVERIES TO CALIF.
ORDER TOTAL
I HAVE ATTACHED MY DESIGN HEREWITH.
YOU ARE AUTHORIZED TO CHARGE THE ABOVE TOTAL PLUS SHIPPING & HANDLING TO MY:
Mastercard VISA

Card Holder Name
Credit Card Number
Expiration date

Card Holder Signature _______________________________________

(order form must be signed)

MILITARY
CLUTCH
JEWELERS
TIE TAC
SAFETY
CLASP
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3424 WEST MAGNOLIA BLVD • BURBANK, CA 91505
POST OFFICE BOX 6369 • BURBANK, CA 91510-6369
TELEPHONE: (818) 848-7223 • FAX: (818) 848-7302


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