Please
use dark ink
Name:
__________________________________________________________________
Address: ________________________________________________________________
City: ___________________________________________________________________
State: ____________________Zip: ___________________________________________
Phone: _________________E-mail (to confirm your order only): __________________________
Payment: (circle one) American Express Visa MasterCard Check Money Order
Credit Card #: _________________________________________Exp. Date: __________
Name on card: ___________________________________________________________
Name & date to be engraved on glass (no charge): _______________________________
_______________________________________________________________________
* Extra engraving (Verse or poem,
50 cents a letter):
_____________________________
_______________________________________________________________________
_______________________________________________________________________
Where on the urn do you want the
engraving, if any: ____________________________
________________________________________________________________________
Urn
description, size &
color:
Price:
1. _____________________________________________________$________
2. _____________________________________________________$________
*Extra engraving: $________
Pet urns –Shipping/HDL – UPS Ground - $Free
To expedite shipping, call or email for price: $________
Human
urns call for shipping/HDL.
Total: $________