Name:

Shipping Address:

City: State: Zipcode:

Phone Number: Fax Number:

E-Mail Address:

Date Ordered

Date Needed

Please indicate the proper brass emblem for your plate.
Graduation Wedding Birth Anniversary Birthday Corporate Award

Type in words you wish to have engraved or attach to order form when faxing in.
The regular price of $125.00 includes 11 engraved lines. We can engrave up to 15 lines for an additional $20 charge.

Check enclosed for: $

Charge to:VISA MasterCard

Card number:
Expiration date:
CVV No.:
The CVV Number can be found on the back of your credit card in the signature field. It is the last three digits following your card number.

(Filling out this form does not automatically create an order. Use it for manually entering data only. You may print out this reservation form and mail it to us or fax it to (309) 407-4741.) Customized, engraved products are non-returnable.)

ITEM DESCRIPTION	Unit Price	Up to 4 extra lines engraved	Quantity	Normal Delivery	Rush Delivery	VA Residents add 4.5% sales tax	TOTAL
Celebration Plate	$125.00	$20.00		$10.50	$55.00