Date ________________                                                                        

Customer Name _____________________ *             

Street # or PO Box ___________________ *
                        
                             City ___________________ *
                      
                           State ___________________ *
 
                  Zip Code ___________________ *



Plain - $55 _____

Basket Stamped - $82 _____

Floral Tooled - $100 _____


Options:

Lined and Stitched - Yes _____ (add $20)
                                            No _____

Dyed - Yes _____ (add $15)
                No _____
If yes, indicate color: Black _____  Mahogany _____
                                            Cordovan _____

Initials/Brand - Yes _____ (add $15)
                                   No _____


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Total (base price + all options) _______________

Due with order (50% of total) _______________

Due on completion (remaining 50%) _______________

Or Payment in Full _______________

Phone number (___)______________ *

                 E-mail __________________

  * indicates a required field











Waist Measurement ______________


Back Color ________________






Silver - Yes _____ (add $6 each piece)
                No _____


Filigree - Yes _____ (add $25)
                    No _____
If yes, indicate filigree color __________________



~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Print this page, mark desired options and send with cashier's check
 or postal money order for the amount at left to:

Empire Leather Company
Brett Buchanan, Maker
PO Box 262
Durkee, OR 97905