On-line order form

Al Dagel, "A Name You Can Trust!"

* indicates required information.	Plaques of Pride order form.
* Your Name:
* Address 1:
Address 2:
* City:
* State or Province:
* Postal Code:
* E-Mail:
* Phone:	Fax :
Best time to call:
	Shipping address, if different:
* Your Name:
* Address 1:
Address 2:
* City:
* State or Province:
* Postal Code:

		Needed:	$
		Needed:	$
		Needed:	$
Print & fill out this form. Place clean or new patch in sturdy envelope. Make check out to AL DAGEL, and enclose it. Remember, the finished product depends on the quality of your original. Don't fold or staple your patch. Mail to:	Subtotal:		$
	Shipping: $12.95 (each, 1st 4) + $4.95 (each over 4)	Needed:	$
	Colorado resident? Check the box.	Colorado Sales Tax:	$
	Order Total:		$
Al Dagel, "A Name You Can Trust!" 2216 West Street Pueblo, CO 81003-1816