Memories in Bronze

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Telephone
E-mail

          Please provide the following product information:

Desired finish:	--Select Finish-- Bronze Pewter Silver Gold
Number of shoes:
Item #:	000 - pair of baby shoes (unmounted) 001 - single baby shoe (unmounted) 003 - single child's shoe (unmounted) 004 - pair of children shoes (unmounted) 105 - two shoes, wood base, 4x6 frame 120 - one shoe, wood base, 5x7 frame 125 - two shoes, wood base, 5x7 frame 126 - two shoes, wood base, 8x10 frame 127 - two shoes, wood base, 5x7 frame 130 - one shoe on wood base 132 - two shoes on wood base 135 - two shoes on wood base 150 -  shoes on wood bookend bases 200 - two shoes, wood base, 8x10 frame 210 - two shoes, wood base, 5x7 frame 300 - one shoe on marble base 310 - shoes on marble bookend base 330 - two shoes on marble or onyx base 400 - two shoes, bronze base, 8x10 frame

Payment Method	--Choose Method of Payment-- VISA MasterCard Check Money Order
Cardholder Name
Card Number
Expiration Date

Signature
	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

          If ordering a wood base:                       --Select Wood Base-- Oak Walnut

          If ordering a marble base:                      --Select Marble Base-- Black Marble White Onyx  

          Please select type style for engraving:    --Select Type Style-- Block Script   

          Special Instructions:         

                                                                                                                            Sub Total 

                Shipping* 

Total 

*Standard shipping charges are:                                                                 

   $12.95 for unmounted baby shoes                                                            

$15.95 for mounted baby shoes, unmounted adult shoes, boots, hats, etc., 

 $25.95 for mounted adult shoes, boots, hats and large items.