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

 

Name:

________________________________________________________*
 

Address:

________________________________________________________*
 

City:

____________________State_________Zip Code______________*
 

Phone:

 ________________________________________________________* 
 

Email:

 ________________________________________________________* 
 

Item being sent:

 ________________________________________________________
    Personalized Inscription
(shoe mounts only)
 

To:

__________________________ From_________________________
     
 

Mount Desired:

 _____________________________________or No Mount:_________
 

Marble/Granite Color:

_____________(Black or White)
 

Finish:

_____________ (for porcelain-like, silver, or pewter add $70.00)    
 
Nameplate (Optional. Add $12.00)		    
 

Name:

___________________________

DOB:

______________
 

Payment Method:

Check Money Order Visa Mastercard    
 

Credit Card #:

_________________________________________    
 

Exp. Date:
(mo/yy)

_______________Security Code:____________    
         
 

Subtotal

     
    If you are sending multiple orders deduct 10%    
    Missouri Residents add 7.975% Sales Tax    
    Return Shipping and Insurance (US Residents)$18.00    
 

Total:

______________    

Signature:

_______________________________________
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Copyright© Family Heirlooms
3950 N 20th Street, Ozark, MO 65721
October 24, 2013
Contact: Customer Service
  1-800-672-0861