PatchPlaqueS.net / Eagle Gifts Galore: Deluxe Ceremony Plaque Order Form

EAGLE GIFTS GALORE
2063 S. HELLMAN AVE., SUITE C, ONTARIO, CA 91761 Voice: (909) 947-6634
Fax: (909) 947-6666 e-Mail: egg@eaglegiftsgalore.net http://www.PatchPlaques.net

DELUXE ARROW CEREMONY
MY PINS and PATCHES PLAQUE ORDER FORM

If you are ordering a plaque for your son, use this form. If you are ordering plaques for several boys,
it is not neccessary to fill out a separate form for each boy, just use the Multi Plaque Order Form

Enter the date each rank was earned in the boxes next to the rank names. If exact date is not known, enter month & year, or year only.
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.

PLAQUE INFORMATION
Name	Order Date: - -
Pack Number	Date plaque is needed: - -
Rank Patch ouline will be Oval unless box is checked.	Diamond Patch
Rank Patch Date: - -	Arrow Patch Date: - -

ORDER SUMMARY

Deluxe Plaque	=	$ 49.95
7.75% Calif. Sales Tax*	=	$ 3.87
Shiping & Handling	=	$ 10.00
Grand Total	=
* California Residents only

Billing Address
Parent's Name	Home Phone - -
Address 1	City
Address 2	State	Zip
E-Mail	Cell/Wk Phone - -

Shipping Address (if different)
Name	Phone - -
Address 1	City
Address 2	State	Zip
We must have a phone number for the shipping address.

EAGLE GIFTS GALORE
2063 S. HELLMAN AVE., SUITE C, ONTARIO, CA 91761 Voice: (909) 947-6634
Fax: (909) 947-6666 e-Mail: egg@eaglegiftsgalore.net http://www.PatchPlaques.net

DELUXE ARROW CEREMONY
MY PINS and PATCHES PLAQUE ORDER FORM
Page 2

PAYMENT INFORMATION:

Check Enclosed

Please charge my Credit Card

CREDIT CARD INFORMATION:

Name on Credit Card:

First Name

Middle Name

Last Name

Please make sure that the Billing Address (above)
is where the credit card statement is sent.

Credit Card Type: Visa Mastercard

CREDIT CARD NUMBER:

EXPIRATION DATE

Signature: _____________________________________________________