Date ________________                                                                        

Customer Name _____________________ *             

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


Base Price

Plain - $72 _____

Basket Stamped - $82 _____

Floral Stamped- $93 _____


Options

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

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

Silver - Yes _____ (add $6 each piece)
                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









One piece cover _____     Three piece cover _____

Spine width ___________    Spine Height __________

Front cover width __________     Front cover height __________

Liner color _______________





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


Clasp - Yes _____ (add $15)
                No _____




~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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