(Click on form, print,  and mail to:)

Custom Engraved Belt Buckles

Name _________________________________________________

Address _______________________________________________

City ___________________________  State ______ Zip ________

Country _________________

Telephone No. _____________________________

E-Mail address __________________________________

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Item: _________________________

Quantity: _____   Price: ______  Total: _________

Name on Buckle: _________________________

With Figure? _________

Item: _________________________

Quantity: _____ Price: ______ Total: _________

Name on Buckle: _________________________

With Figure? _________

Item: _________________________

Quantity: _____ Price: ______ Total: _________

Name on Buckle: _________________________

With Figure? _________

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Visa or MasterCard No. __________________________

Expires: __________

Signature: ______________________________________

(Or send check to:)

Capital Engraving
3109 Marigold St.
Longview, Wa. 98632-3415
Phone or FAX (360) 575-1408
1-800-628-4985