Wine Glass Order Form
   Please print out this form and mail with payment,  or  email  me to place your order.
Send to: GLASS TATTOO
P.O.Box 909
29 Palms, Calif. 92277-0909
Single Heart 215
Single Heart 224
Single Heart 228
Double Heart 215
Double Heart 224
Double Heart 228
 Wine Glasses   Links Page     Main Page
           Reversed Names come Julie / Chris on one glass and Chris / Julie on the other glass.
Single heart has one name per glass.

|Italics/Am.Std | Design # | First Name    | First Name    |Reverse Names |   Date                          | Each       |  Price / Set  $22.00 |
|Example |  Italics  |  DH 228  |  Julie              |  Chris                |  Yes                   |                                      | $12.50               |     $22.00           |
|                            |                   |                         |                           |                            |                                      |                           |                           |
|                            |                   |                         |                           |                            |                                      |                           |                           |
|                            |                   |                         |                           |                            |                                      |                           |                           |
                                                                                                                                                                                 Pre - Total |                            |
                                                                                                                                                                 Add Ship/Handling |        $10.50         |
                                                                                 Insurance     |      _ $1.85__       |
Please Print this order form, fill out and mail with your payment. One set per order.                         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 (please call or email me for rush orders)


Received_____________   Shipped______________

updated 10/02/08