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All prices in US dollars

Lord's Fine Jewelry ORDER FORM

P.O. Box 486
Piedmont, OK 73078
(405) 373-2877

MAILING ADDRESS

NAME:__________________________________________________________________________

ADDRESS:_______________________________________________________________________

CITY:___________________________ STATE:___________ ZIP:__________________________

DAYTIME PHONE:_______________________________________________________________

Item Number:_____________________ Quantity:_________

Ring Size:__________________

Chain Length:_______________

Initials (if desired):___ ___ ___

Item Price:_________________

Engraving Costs:____________
75 cents for each character
( $5.00 minimum)

Shipping:___________________ ------------------------------------ Sub Total:________________
Regular $6.00, Overnight $12.50 -------- Sales Tax (OK residents only):________________

---------------------------------------------------------------------------- Grand Total:________________

METHOD OF PAYMENT:___________________________________

[__] Check or money order enclosed (Sorry, no C.O.D.s)

[__] Charge to your credit card. Please provide your correct billing address if different from your mailing address. For your protection, we verify credit card oerders by your billing address.

Please check the card used:

[__] VISA [__] Mastercard

[__] Discover [__] American Express

Account number:___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| Expiration date:________

Signature (as it appears on the card):___________________________________________________________