Plain Wine Glass Order Form
(no frosted stem or date)
Please print out this form and mail it with payment,   or  email  me to place your order.
Send to: GLASS TATTOO
P.O.Box 909
29 Palms, Calif. 92277-0909

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Reversed Names come Julie / Chris on one glass and Chris / Julie on the other glass.
Single heart and other designs have one name per glass.

|Italics/Am.Std | Design         | First Name    | First Name    |Reverse Names  | Each       |  Price / Set  $14.00 |
|Example |  Italics  | Anniv            |  Julie              |  Chris                |  Yes                 |     $8.00    |            $14.00           |
|                      |                           |                         |                           |                             |                          |                            |
|                      |                           |                         |                           |                             |                           |                            |
|                      |                           |                         |                           |                             |                           |                            |
                                                                                                                                            Pre - Total |                             |
                                                                                                                            Add Ship/Handling |        $10.50          | per set
                                                                                                                              Insurance per set   |        _$1.85          |
                                                                                                                                    Total Enclosed |                             |

Ship to:                                                                        Please be SURE that the information
Name__________________________________         you have provided is ACCURATE!!
Mailing Address_________________________        This is a sandblast process through a
City_________________State______________         handcut stencil.  Once the design and
Zip+4_______________                                               names are on the glass, they can not
E-mail address__________________________          be removed!
Phone Number___________________________

Method of payment (check one)  [ ] Visa  [ ] M/C  [ ] Discover   [ ] Money Order

Name on card_______________________
Card Number_______________________
Expiration Date_____________________
Signature________________________

Allow 4-6 weeks for delivery
Received_____________   Shipped______________
updated 10/02/08