NAME ( PLEASE PRINT )__________________________C/O _________________

                                                                                    ADDRESS___________________________________    

EMAIL ADDRESS_____________________________

DAYTIME PHONE AREA CODE _______ ___________________________ EXTENSION______________________

____ CHECK OR MONEY ORDER $ __________ /___VISA   ____ MASTER CHARGE   ___AMERICAN EX.

MONTH AND YEAR OF EXPIRATION ____/____ SIGNATURE ___________________________________

(WE CANNOT PROCESS YOUR ORDER WITHOUT THE EXPIRATION DATE )

8 " INCH PORCELAIN PHOTO PLATE

10 " INCH PORCELAIN PHOTO PLATE

QTY____________ PRICE EACH X $44.95 =                                      TOTAL 10-INCH __________________

PLATE PERSONALIZATION     QTY. ____       EACH X $5.00 charge  = TOTAL_____________

* * * * * 2 LINES OF 22 CHARACTERS  INCLUDING SPACES ( PLEASE PRINT CLEARLY   ) * * * * *

LINE1_________________________________________________________________________

GIFT KIT   Includes 8-inch plate,  stand , & PRIORITY MAIL ship/hand.  We send you the SPECIAL MAILER & GIFT Certificate to Give as a Gift . The recipient then  sends in the mailer , ADDRESS INFO & photo    They get an 8" PICTURE PLATE  IN RETURN AS YOUR GIFT, No invoice or bill is sent with the gift plate  ! 

QTY___________ PRICE EACH X $49.95 = ______ TOTAL KITS ______________

 ____3" INCH PORCELAIN PHOTO PLATE  OR ____3 x 4 INCH CHINA ORNAMENT

QTY.___________ PRICE per 2 (of same photo  ) = $34.95        TOTAL 3 inch  _________________

PLATE STAND QTY. ________ PRICE EA. X $2.25 ________= TOTAL STANDS _________________

  8 x 10 STRETCHED CANVAS PRICE EACH X $ 39.95 _________

                                                                                                           SUB TOTAL ___________________ 

PLEASE CHECK ONE BOX                          SHIPPING CHARGE __________________

___ STANDARD $8.50 PER ITEM  (priority mail in USA )                    Sales TAX _______________( N.Y. State only - 8.75% )

___ GIFT KIT ONLY  $2.00 PER ITEM 

___ EXPRESS (1 day ) $ 25.00 PER ITEM                                    ORDER TOTAL  __________________________

Please label the back of each picture with your name and address , allow 4 to 6 weeks for delivery

DO NOT CUT or DRAW ON YOUR PHOTOS , WE NEED THE ENTIRE PICTURE !!

      Your Photos will be returned with your order !!          ~ THANK YOU ~

TEAR HERE AND SAVE FOR YOUR RECORD

WHAT YOU ORDERED ___________ METHOD OF PAYMENT ______________

DATE ORDERED _________

Picture Plates P.O. BOX 2 , ISLAND PARK , N.Y. 11558 516 678 -5161 

EMAIL pictplates@aol.com                       http://www.pictureplates.com