THE SCOUT IMAGE
2063 S. HELLMAN AVE., SUITE C, ONTARIO, CA 91761   Voice: (909) 947-6634
Fax: (909) 947-6666 e-Mail:  tsi@TheScoutImage.com     http://www.ScoutPlaques.com
CUB   SCOUT  THANK  YOU  POEM  PLAQUE
ORDER  FORM

If you are ordering a Cub Scout Thank You Poem Plaque, use this form.
For Boy Scout Thank You Poem Plaques, please use the Boy Scout Thank You Poem Plaque Order Form.
For Deluxe Poem Plaques, please use the Deluxe Poem Plaque Order Form.

ORDER  FORM  INSTRUCTIONS
1.Enter your Background Paper choice.   (See Background Papers pages.)
2. Select Poem.  (See Thank You Poem Plaques page for poem choices & wording.)
3.Select Plaque color.*      7. Total your order.
4. Fill in Date plaque is needed by.      8. Fill in your contact information.
5.Enter your Pack # and Council Name.**      9. Fill in payment information.
6. Enter your Personal Message.    10. Print Form.
*Some background papers look better in Walnut, some in Black Marble.
If you prefer, we can choose the best plaque color for your background paper choice.
**This information will help us to determine if your leader has already received the poem you are ordering for him or her.
Use your browser's "Print" feature to print this form, sign it, and Fax or mail it to the address above.

Please do NOT send Credit Card information via eMail.


          Poem Plaque                       $ 24.95 Each
Shipping and Handling       $ 10.00

California Residents add 7.75% Sales Tax

POEM INFORMATION
Background Paper:  
Select Poem:    Poem
Select plaque color:  
Date plaque is needed by:   - -
Pack Number:  
Council Name:  
Personal Message
Leader's Name or Line 1
Sentiment or Line 2
Scout (or Den) Name & Date or Line 3

* * * * * * * * * * * * * * * * * * * * * * * *


ORDER   SUMMARY
  Poem Plaque  @  $ 24.95  =  $ 24.95
  California Sales Tax*   @    7.75%    =   $   1.93
  Shiping & Handling   @  $ 10.00  = $ 10.00
  Total    = 
* California Residents only

Billing Address
Parent's Name
Address 1
Address 2
City
State
Zip
Home Phone
- - 		Cell/Work Phone
- -
E-Mail
Shipping Address (if different)
Parent's Name
Address 1
Address 2
City
State
Zip
Phone
- -
We must have a phone number for the shipping address.



PAYMENT   INFORMATION:
 Check Enclosed
 Please charge my Credit Card
CREDIT  CARD   INFORMATION:
Name on Credit Card:
First NameMiddle NameLast Name
Please make sure that the Billing Address (above) is where the credit card statement is sent.
  Credit Card Type:     
CREDIT   CARD   NUMBER: EXPIRATION   DATE
        
Signature: _____________________________________________________


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