Ship to (Please PRINT and fill in ALL information)

Name                                                                                                                                                   DATE

Address 

City/State/Zip Code

Phone Number 

Credit Card Information or Pay by Check (enclose check with order form)

Name on Credit Card 

Credit Card Number 

Expiration date                                                                                                    Credit Card Billing Zip Code

Signature of Cardholder                                                                                                                               3 Digit Code

Check One

Item

DESCRIPTION

Amount

Bracelet Style & Price

MA1        $54.00

Pink Crystals

MA2        $78.00

Sterling Silver & 14K Gold Filled

MA3        $54.00

Multi-color Crystals

MA4       $78.00

All Sterling Silver

MA5       $54.00

6mm Clear and White Crystal Mix   

Check One

Pendants

Medical Alert

Medical Alert Pendant

N/C

Breast Cancer Survivor

Breast Cancer Survivor Pendant

N/C

ENGRAVING INSTRUCTIONS (Fill in below)

(Engraving  COST $4.00 per line, example -  3 lines $12.00)
 Line 1 (10 space maximum): 
Line 2 (20 space maximum): 
Line 3 (20 space maximum): 
Line 4 (10 space maximum): 

 ($4.00 per line)

Bracelet Sizing

CLASP CHOICE (check one)

 All Bracelets will fit wrist sizes 7, 7.5 and 8 inches and come with your choice of a triple toggle or lobster claw with chain extender.  For other sizes please contact us.

Triple Toggle    _______

Lobster Claw with chain extender_______

N/C

SUB-TOTAL

6% TAX only if ordering in the State of  GA

SHIPPING & HANDLING  via FedEx  $8.00 up to 3 bracelets  $10.00 4 or more bracelets

GRAND TOTAL