PatchPlaque Order Form

Simulated Wood Background/Key Rack Order Form

PLAQUE DESCRIPTION

Description of Original:
Install Hooks for Key Rack? YES_____   NO_____

BACKGROUND SELECTION:

Contemporary Black   Contemporary White   Light Oak   Rosewood   Walnut

INLAY SELECTION:

Gold   Silver   None

PERSONALIZED TAB

Would you like the personalized version?

Yes   No

If YES, then please enter the following - maximum 4 lines of text and 28 characters per line

Line 1:

Line 2:

Line 3:

Line 4:

ORDER PRICING

Total of ________ Key Rack(s) ordered at $ 49.95 each = $ _____________

Total of ________ Metallic Image(s) at $ 10.00 each = $ _____________

Total of ________ Personalized Option(s) at $ 12.95 each = $ _____________

Florida Residents Please Add Florida and YOUR County sales tax = $ _____________

Shipping and Handling charges are included!
Total   = $ _____________

SHIPPING INFORMATION (additional charges apply for shipments outside of the Continental USA)

Name:

Street Address:

Suite/Apt.:

City: State:           Zip:

Phone (Days): (Eves):

Email address:

BILLING INFORMATION (leave blank if address is the same as shipping address)

Name:

Address:

Suite/Apt.:

City: State:           Zip:

Phone (Days): (Eves):

METHOD OF PAYMENT

   Check or Money Order

Account #: Expiration:

Signature: Security Code:

INSTRUCTIONS

Please print the following form, fill it out, and then send it to us. Be sure to include your patch / item and payment. Because every order is a Custom Order, we can not ship COD. Colors of the reproduced patch / item as a finished key rack may vary slightly.

NOTICE

The overall quality of your finished plaque is directly related to the condition of the original patch or image that you provide to us. Try to give us the cleanest item possible. Do not staple, paper clip, or fold the item. Simply place the item within a clean piece of folded white paper and send it to us, along with the completed order form, in any envelope that fits. Your key rack will be shipped to you within two weeks.
If your patch / item is valuable, we recommend that you insure it when you send it to us.
In the event that PatchPlaques.com loses or accidentally destroys your patch / item, we will replace it when possible or refund the replacement cost, not to exceed twenty five dollars ($25.00), as exclusive remedy.

Please send your patch, this completed order form, and your payment via U.S. Postal Service to:

PatchPlaques.com
P.O. Box 250180
Daytona Beach, FL 32125

If you are sending via UPS, FEDEX or DHL then send your order to:

PatchPlaques.com
338 Parque Drive, Suite F
Ormond Beach, FL 32174

If you have any questions about your order, contact us at:

info@patchplaques.com

Phone, toll free, (888) 671-2130

Fax (386) 676-9117

We sincerely appreciate your business!