Shrine
Bowl Ring
Order Form
| Name: |
_________________________ |
| Address: |
_________________________ |
|
____________________________ |
| Phone: |
_________________________ |
| Ring Size: |
________ |
Initials: |
________ |
| State: |
NC |
or |
SC |
| |
Player |
or |
Coach |
| Player #: |
________ |
Position: |
_________ |
| Year Played or Coached: |
_________ |
| Metal Choice: |
| z Lustrium |
| z Yellow Lustrium |
| |
| 10K Gold |
| z Yellow z
White |
| |
| Payment Type: |
| z Check |
| z Money Order |
| z Credit Card |
|
| Price $ _______ |
| |
| Sales Tax ______ |
| |
| Total __________ |
| |
| Deposit ________ |
| |
| Balance ________ |
| |
| |
|
Credit Card Information
| z
Visa |
z
MasterCard |
z
Discover |
| Amount
$__ __ __ .__ __ |
Exp.
Date: __ __/__ __ |
|
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ |
| Credit
Card Number |
|
| _________________________________________ |
| Cardholder's
Signature |
|
|
The Championship Specialists:
Dick Conn & Associates
P.O. Box 172573
Spartanburg, SC 29301